Individual
DETRA SHAUNTEL SIMPO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OTR/L
Contact information
Practice address
518 DRY BRANCH WAY, ST JOHNS, FL 32259-6203
(904) 382-7886
Mailing address
518 DRY BRANCH WAY, ST JOHNS, FL 32259-6203
(904) 382-7886
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT9940
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
024815600
—
FL
01
—
Z9346
BCBS
FL
Enumeration date
10/02/2006
Last updated
09/01/2020
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