Healthcare Provider Details

I. General information

NPI: 1255969317
Provider Name (Legal Business Name): GABRIEL BERNARDO CUESTA COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15354 SW 36TH TER
MIAMI FL
33185-4701
US

IV. Provider business mailing address

15354 SW 36TH TER
MIAMI FL
33185-4701
US

V. Phone/Fax

Practice location:
  • Phone: 786-509-0924
  • Fax:
Mailing address:
  • Phone: 786-509-0924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number17168
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: