Basic Information
Provider Information | |||||||||
NPI: | 1689225914 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAKITA | ||||||||
FirstName: | ILANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | COTA/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RAKITA | ||||||||
OtherFirstName: | ILANA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | COTA/L | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2520 N MCMULLEN BOOTH RD STE B208 | ||||||||
Address2: |   | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337614181 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7275036482 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 111 FAIRGROUND RD | ||||||||
Address2: |   | ||||||||
City: | GLENVILLE | ||||||||
State: | WV | ||||||||
PostalCode: | 263511388 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044625718 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2019 | ||||||||
LastUpdateDate: | 09/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | C2289 | WV | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   |
No ID Information.