MEDICARE: MRS. SANDRA GARCIA COTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	OTA13601	FL

General Provider Information

NPI Number	:	1225436538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA GARCIA COTA

Provider Business Mailing Address
First Line	:	3311 BROADVIEW CIR
Second Line	:
City	:	CRESTVIEW
State	:	FL
Zip	:	32539-8633
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 LOWERY PL SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5547
Country	:	US
Telephone Number	:	850-566-8974
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2014
Last Update Date	:	12/18/2014

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