Healthcare Provider Details

I. General information

NPI: 1346902285
Provider Name (Legal Business Name): CHARBEE BALDERSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12170 CORTEZ BLVD
BROOKSVILLE FL
34613-5578
US

IV. Provider business mailing address

1039 BARLOW CT
SPRING HILL FL
34606-5602
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-5100
  • Fax:
Mailing address:
  • Phone: 727-656-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA18598
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: