Provider Demographics
NPI:1104436435
Name:BEASLEY, GABRIELLE GRACE (COTA)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:GRACE
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 EASTSIDE LN
Mailing Address - Street 2:
Mailing Address - City:OSTEEN
Mailing Address - State:FL
Mailing Address - Zip Code:32764-9428
Mailing Address - Country:US
Mailing Address - Phone:407-947-1715
Mailing Address - Fax:
Practice Address - Street 1:1935 STATE ROAD 436 STE 500
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2244
Practice Address - Country:US
Practice Address - Phone:407-629-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA17863224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant