Provider Demographics
NPI:1588325997
Name:ANDERSON, T'KEYAH JAJUAN (OTD)
Entity type:Individual
Prefix:
First Name:T'KEYAH
Middle Name:JAJUAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 1ST AVE S STE 200-161
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4361
Mailing Address - Country:US
Mailing Address - Phone:727-803-1102
Mailing Address - Fax:727-502-6027
Practice Address - Street 1:4175 E BAY DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-6985
Practice Address - Country:US
Practice Address - Phone:727-803-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT22576225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist