Provider Demographics
NPI:1104245356
Name:TUCKER, KIMBERLY ANN (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:ROTHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:6508 GUNN HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625
Mailing Address - Country:US
Mailing Address - Phone:813-963-6923
Mailing Address - Fax:813-264-0768
Practice Address - Street 1:6508 GUNN HIGHWAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625
Practice Address - Country:US
Practice Address - Phone:813-963-6923
Practice Address - Fax:813-264-0768
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010928100Medicaid