Provider Demographics
NPI:1912301409
Name:SAMUELS TAYLOR, STACEY-ANN (COTA)
Entity Type:Individual
Prefix:
First Name:STACEY-ANN
Middle Name:
Last Name:SAMUELS TAYLOR
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 1:6608 CAMDEN BAY DR
Mailing Address - Street 2:# 303
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-9084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6608 CAMDEN BAY DRIVE
Practice Address - Street 2:# 303
Practice Address - City:TAMPA
Practice Address - State:TAMPA
Practice Address - Zip Code:33635
Practice Address - Country:UM
Practice Address - Phone:860-913-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13010171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor