Provider Demographics
NPI:1801135355
Name:DETHOMAS, DEANNA M (OTR)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:M
Last Name:DETHOMAS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:
Other - Last Name:DETHOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:6019 BROAD RIVER RUN
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-7270
Mailing Address - Country:US
Mailing Address - Phone:914-712-5198
Mailing Address - Fax:
Practice Address - Street 1:7333 INTERNATIONAL PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8418
Practice Address - Country:US
Practice Address - Phone:914-712-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5276225X00000X
NY018042-1225X00000X
FLOT20466225X00000X
P86854225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114633100Medicaid