Provider Demographics
NPI:1508686262
Name:GREGORY, BIANCA (COTA/L)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22391 FLORA PARKE XING UNIT A
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8005
Mailing Address - Country:US
Mailing Address - Phone:678-761-2863
Mailing Address - Fax:855-565-1769
Practice Address - Street 1:22391 FLORA PARKE XING UNIT A
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-8005
Practice Address - Country:US
Practice Address - Phone:678-761-2863
Practice Address - Fax:855-565-1769
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18645224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant