Provider Demographics
NPI:1962649103
Name:PORCO, KRISTIAN MARIE (MSOTR/L)
Entity type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:MARIE
Last Name:PORCO
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7345 NW 1ST MNR
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2271
Mailing Address - Country:US
Mailing Address - Phone:352-613-6615
Mailing Address - Fax:
Practice Address - Street 1:3947 PROMENADE SQUARE DR APT 4014
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-3373
Practice Address - Country:US
Practice Address - Phone:954-348-2392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 13339225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics