Provider Demographics
NPI:1770110835
Name:DETRIO, KIMBERLY (COTA/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DETRIO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S SWOOPE AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5784
Mailing Address - Country:US
Mailing Address - Phone:321-972-4122
Mailing Address - Fax:407-542-2168
Practice Address - Street 1:125 S SWOOPE AVE STE 210
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5784
Practice Address - Country:US
Practice Address - Phone:321-972-4122
Practice Address - Fax:407-542-2168
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10512224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant