Healthcare Provider Details

I. General information

NPI: 1164262309
Provider Name (Legal Business Name): KAIA RAE HIGGINBOTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 3RD ST
ROCKLEDGE FL
32955-5703
US

IV. Provider business mailing address

1303 WORTH CT NE
PALM BAY FL
32905-4347
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-8792
  • Fax:
Mailing address:
  • Phone: 321-368-0569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT25248
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: