Provider Demographics
NPI:1184087751
Name:CAMPBELL, TAWANA (COTA)
Entity type:Individual
Prefix:
First Name:TAWANA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 BLACK CORAL AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-9493
Mailing Address - Country:US
Mailing Address - Phone:321-750-6809
Mailing Address - Fax:
Practice Address - Street 1:926 BLACK CORAL AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-9493
Practice Address - Country:US
Practice Address - Phone:321-750-6809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10729224Z00000X
WAOC60632347225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist