Healthcare Provider Details

I. General information

NPI: 1235596198
Provider Name (Legal Business Name): MICHELLE LOPEZ COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2016
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 GRESHAM DR
ORLANDO FL
32807-6409
US

IV. Provider business mailing address

2415 GRESHAM DR
ORLANDO FL
32807-6409
US

V. Phone/Fax

Practice location:
  • Phone: 407-595-6215
  • Fax:
Mailing address:
  • Phone: 407-595-6215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberOTA13400
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA13400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: