=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407338395
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIZETTE M VASQUEZ COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2018
-----------------------------------------------------
Last Update Date | 09/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5285 SW 40TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33314-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-294-1446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5285 SW 40TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33314-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-294-1446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | OTA16791
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------