MEDICARE: SHAWANA D SMITH COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	16892	FL

General Provider Information

NPI Number	:	1104395607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWANA D SMITH COTA/L

Provider Business Mailing Address
First Line	:	2496 W 28TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-3553
Country	:	US
Telephone Number	:	904-861-7434
Fax Number	:

Provider Business Practice Location Address
First Line	:	2496 WEST 28TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-3220
Country	:	US
Telephone Number	:	904-861-7434
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2018
Last Update Date	:	11/14/2018

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