Provider Demographics
NPI:1679283352
Name:LEYVA ACOSTA, GRETTY
Entity type:Individual
Prefix:
First Name:GRETTY
Middle Name:
Last Name:LEYVA ACOSTA
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 1:2629 DEL PRADO BLVD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5769
Mailing Address - Country:US
Mailing Address - Phone:239-574-4434
Mailing Address - Fax:239-574-6968
Practice Address - Street 1:2629 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5769
Practice Address - Country:US
Practice Address - Phone:239-574-4434
Practice Address - Fax:239-574-6968
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA19214224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant