Healthcare Provider Details

I. General information

NPI: 1992106140
Provider Name (Legal Business Name): GUY ADRIEN HOUSE COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12170 CORTEZ BLVD
BROOKSVILLE FL
34613-5578
US

IV. Provider business mailing address

25442 WILLOW ST
BROOKSVILLE FL
34601-4724
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-5100
  • Fax:
Mailing address:
  • Phone: 352-587-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA 13774
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: