Healthcare Provider Details

I. General information

NPI: 1891659595
Provider Name (Legal Business Name): BIANCA ELENA SOUKOVA JEAN OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3227 HILLSDALE LN
KISSIMMEE FL
34741-7561
US

IV. Provider business mailing address

2630 PLEDGE RD APT 203
KISSIMMEE FL
34741-7875
US

V. Phone/Fax

Practice location:
  • Phone: 407-990-2847
  • Fax:
Mailing address:
  • Phone: 786-419-5139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA16579
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: