Provider Demographics
NPI:1871165266
Name:PUCKETT, ANDREA KAY (COTA/L)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:KAY
Last Name:PUCKETT
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 1:6300 COUNTY ROAD 561
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-9171
Mailing Address - Country:US
Mailing Address - Phone:352-638-7679
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:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17505224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant