MEDICARE: MRS. AYESHA M HARRIS COTA/L, CAPS

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
2	224ZL0004X	Low Vision Occupational Therapy Assistant
3	224ZR0403X	Driving and Community Mobility Occupational Therapy Assistant
4	224ZE0001X	Environmental Modification Occupational Therapy Assistant	OTA13216	FL

General Provider Information

NPI Number	:	1649817735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AYESHA M HARRIS COTA/L, CAPS

Provider Business Mailing Address
First Line	:	PO BOX 17391
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32245-7391
Country	:	US
Telephone Number	:	904-800-9874
Fax Number	:

Provider Business Practice Location Address
First Line	:	13521 STONE POND DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-1626
Country	:	US
Telephone Number	:	904-800-9874
Fax Number	:

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

Provider Enumeration Date	:	12/08/2019
Last Update Date	:	12/08/2019

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