Provider Demographics
NPI:1336726157
Name:KEITT, TANYA SHIRRELL (COTA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:SHIRRELL
Last Name:KEITT
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 1:500 W 164TH ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4246
Mailing Address - Country:US
Mailing Address - Phone:347-789-0807
Mailing Address - Fax:
Practice Address - Street 1:301 ORIENTAL BLVD APT 1F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4146
Practice Address - Country:US
Practice Address - Phone:347-286-6194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010686224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant