Healthcare Provider Details

I. General information

NPI: 1427562800
Provider Name (Legal Business Name): JOY CARISSA KECKLER COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 09/29/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 CROTON AVE
DELTONA FL
32738-1479
US

IV. Provider business mailing address

3301 CROTON AVE
DELTONA FL
32738-1479
US

V. Phone/Fax

Practice location:
  • Phone: 386-848-5875
  • Fax:
Mailing address:
  • Phone: 386-848-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number16114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: