=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881495208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA DACOSTA COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2025
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2667 ENTERPRISE RD
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-8217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-233-3534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 787 CRAWFORD ST
-----------------------------------------------------
City | DELTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32725-9234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-848-2269
-----------------------------------------------------
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 | 13519
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------