Provider Demographics
NPI:1023624566
Name:COLBY, COREY KEVIN (COTA/L)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:KEVIN
Last Name:COLBY
Suffix:
Gender:M
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 1:5104 ARMOR RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33567-2662
Mailing Address - Country:US
Mailing Address - Phone:904-233-0611
Mailing Address - Fax:
Practice Address - Street 1:610 E BELLA VISTA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3008
Practice Address - Country:US
Practice Address - Phone:863-688-8591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17667224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant