Healthcare Provider Details

I. General information

NPI: 1295463966
Provider Name (Legal Business Name): GISELLE BARRIENTOS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W VINE ST
KISSIMMEE FL
34741-4643
US

IV. Provider business mailing address

2869 BERKSHIRE CIR
KISSIMMEE FL
34743-5655
US

V. Phone/Fax

Practice location:
  • Phone: 321-445-1287
  • Fax: 407-386-7448
Mailing address:
  • Phone: 321-437-1596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number477564
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: