=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740446244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA LEE AZAR COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2008
-----------------------------------------------------
Last Update Date | 08/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 UNIVERSITY PKWY SUITE 218, BLDG. 2
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34243-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-359-9555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 841 TAAGA PL
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34232-1835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-371-6186
-----------------------------------------------------
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 | OTA 10334
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------