Healthcare Provider Details

I. General information

NPI: 1407493554
Provider Name (Legal Business Name): MICHAEL MIFSUD COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 COGSWELL ST STE C24
ROCKLEDGE FL
32955-2740
US

IV. Provider business mailing address

520 WICKHAM LAKES DR
MELBOURNE FL
32940-2216
US

V. Phone/Fax

Practice location:
  • Phone: 321-872-8737
  • Fax:
Mailing address:
  • Phone: 321-243-4605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number17299
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: