=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396913638
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN JONES COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2008
-----------------------------------------------------
Last Update Date | 02/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14302 COBRA WAY
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34669-1011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-774-4700
-----------------------------------------------------
Fax | 727-774-4791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5004 SWALLOW DR
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34639-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-774-4700
-----------------------------------------------------
Fax | 727-774-4791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA05634
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------