=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255925913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL LOCKE NETTLES COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2021
-----------------------------------------------------
Last Update Date | 02/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 NORTH LAKE HOWARD DRIVE
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-268-2615
-----------------------------------------------------
Fax | 863-268-2615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1465 HACKL BLVD
-----------------------------------------------------
City | BARTOW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33830-5922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-393-8797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA18061
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------