Provider Demographics
NPI:1285116368
Name:SIMS, STEPHANIE MALLORY (COTA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MALLORY
Last Name:SIMS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-4220
Mailing Address - Country:US
Mailing Address - Phone:863-399-2332
Mailing Address - Fax:
Practice Address - Street 1:1213 W STRATFORD RD
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-8091
Practice Address - Country:US
Practice Address - Phone:863-399-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11373224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant