Provider Demographics
NPI:1962757757
Name:DESJARDIN, KRISTY MARIE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:MARIE
Last Name:DESJARDIN
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 1:1300 SE 5TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-5613
Mailing Address - Country:US
Mailing Address - Phone:407-879-2845
Mailing Address - Fax:
Practice Address - Street 1:216 SANTA BARBARA BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2031
Practice Address - Country:US
Practice Address - Phone:239-772-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11707224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant