Provider Demographics
NPI:1588868111
Name:PETROPOULOS, BREENDA (COTA)
Entity type:Individual
Prefix:MRS
First Name:BREENDA
Middle Name:
Last Name:PETROPOULOS
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 1:2669 SHANNON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-6343
Mailing Address - Country:US
Mailing Address - Phone:904-312-1310
Mailing Address - Fax:
Practice Address - Street 1:1422 SAN MARCO BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8536
Practice Address - Country:US
Practice Address - Phone:904-398-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10116224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant