Healthcare Provider Details

I. General information

NPI: 1548859184
Provider Name (Legal Business Name): NEVY HULSE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 01/17/2021
Certification Date: 01/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 VONDERBURG DR
BRANDON FL
33511-5900
US

IV. Provider business mailing address

602 VONDERBURG DR
BRANDON FL
33511-5900
US

V. Phone/Fax

Practice location:
  • Phone: 813-653-1149
  • Fax:
Mailing address:
  • Phone: 813-653-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number17957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: