Provider Demographics
NPI:1013263664
Name:RICHARDS, KAYLA BROOKE (OTRL)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:BROOKE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:BROOKE
Other - Last Name:ADCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2104 LEWIS TURNER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1316
Mailing Address - Country:US
Mailing Address - Phone:850-862-3728
Mailing Address - Fax:850-862-6270
Practice Address - Street 1:2104 LEWIS TURNER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1316
Practice Address - Country:US
Practice Address - Phone:850-862-3728
Practice Address - Fax:850-862-6270
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15331225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012179000Medicaid