Healthcare Provider Details

I. General information

NPI: 1093161945
Provider Name (Legal Business Name): BRIDIE FLYNN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2578 ENTERPRISE RD # 116
ORANGE CITY FL
32763-7904
US

IV. Provider business mailing address

2578 ENTERPRISE RD # 116
ORANGE CITY FL
32763-7904
US

V. Phone/Fax

Practice location:
  • Phone: 386-747-7718
  • Fax:
Mailing address:
  • Phone: 386-747-7718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: