Basic Information
| Provider Information | |||||||||
| NPI: | 1790319374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEISINGER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ERIN | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1461 DOZIER CIR SE | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329096531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104887389 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1535 COGSWELL ST STE C24 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218728737 | ||||||||
| FaxNumber: | 3213258073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2020 | ||||||||
| LastUpdateDate: | 02/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 17366 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.