Healthcare Provider Details

I. General information

NPI: 1871146639
Provider Name (Legal Business Name): JULIE ANN HULONGBAYAN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 MARSHALL DR
PERRY FL
32347-1835
US

IV. Provider business mailing address

2313 DEBORAH DR
VALDOSTA GA
31602-2022
US

V. Phone/Fax

Practice location:
  • Phone: 850-584-6334
  • Fax:
Mailing address:
  • Phone: 229-444-8593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA15093
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: