Healthcare Provider Details

I. General information

NPI: 1114833860
Provider Name (Legal Business Name): MA LOURDES PERALTA OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 SOUTHBROOK DR
JACKSONVILLE FL
32256-0601
US

IV. Provider business mailing address

12083 NOGOYA ST
JACKSONVILLE FL
32256-6872
US

V. Phone/Fax

Practice location:
  • Phone: 904-641-7501
  • Fax:
Mailing address:
  • Phone: 904-294-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA16007
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: