Healthcare Provider Details

I. General information

NPI: 1558085365
Provider Name (Legal Business Name): LEAH MICHELLE MISSAL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 WYMORE RD APT 105
ALTAMONTE SPRINGS FL
32714-5110
US

IV. Provider business mailing address

395 WYMORE RD APT 105
ALTAMONTE SPRINGS FL
32714-5110
US

V. Phone/Fax

Practice location:
  • Phone: 407-300-7319
  • Fax:
Mailing address:
  • Phone: 407-300-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number19007
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number19007
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: