Healthcare Provider Details

I. General information

NPI: 1508093170
Provider Name (Legal Business Name): MELY MARIE GAMBA-RIVERA COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17670 NW 78TH AVE SUITE 113
HIALEAH FL
33015-3664
US

IV. Provider business mailing address

6600 CYPRESS RD UNIT 512
PLANTATION FL
33317-3092
US

V. Phone/Fax

Practice location:
  • Phone: 305-512-5757
  • Fax: 305-512-5755
Mailing address:
  • Phone: 954-655-1461
  • Fax: 305-512-5755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA 10491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: