Healthcare Provider Details

I. General information

NPI: 1013630805
Provider Name (Legal Business Name): ANNALIESE LUZ ALICEA COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 ADANSON ST
ORLANDO FL
32804-1331
US

IV. Provider business mailing address

PO BOX 120547
CLERMONT FL
34712-0547
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0212
  • Fax: 352-241-6361
Mailing address:
  • Phone: 352-394-0212
  • Fax: 352-241-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number19167
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: