MEDICARE: LIZETTE M VASQUEZ 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	OTA16791	FL

General Provider Information

NPI Number	:	1407338395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZETTE M VASQUEZ COTA

Provider Business Mailing Address
First Line	:	5285 SW 40TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33314-6501
Country	:	US
Telephone Number	:	954-294-1446
Fax Number	:

Provider Business Practice Location Address
First Line	:	5285 SW 40TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33314-6501
Country	:	US
Telephone Number	:	954-294-1446
Fax Number	:

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

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	09/06/2018

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