Provider Demographics
NPI:1730372111
Name:EUSTACE, KATHLEEN A
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:EUSTACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22279 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5514
Mailing Address - Country:US
Mailing Address - Phone:941-204-7714
Mailing Address - Fax:
Practice Address - Street 1:5901 BROKEN SOUND PKWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2773
Practice Address - Country:US
Practice Address - Phone:800-875-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09061700224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant