Provider Demographics
NPI:1013273689
Name:MAIETTA, EILEEN S (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:S
Last Name:MAIETTA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-2602
Mailing Address - Country:US
Mailing Address - Phone:540-815-0759
Mailing Address - Fax:
Practice Address - Street 1:10100 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5436
Practice Address - Country:US
Practice Address - Phone:800-347-2264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-07
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15185225X00000X
VA0119001028225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist