Provider Demographics
NPI:1174988687
Name:PETRACCA, CHRISTINE LYNN (COTA/L)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:LYNN
Last Name:PETRACCA
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 1:2123 ANCHOR AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2383
Mailing Address - Country:US
Mailing Address - Phone:386-216-2523
Mailing Address - Fax:
Practice Address - Street 1:2123 ANCHOR AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2383
Practice Address - Country:US
Practice Address - Phone:386-216-2523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 14660224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant