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NPI Code Detail

MEDICARE: RUSSELL LAMAR LOCKE SR. COTA/L

MEDICARE: RUSSELL LAMAR LOCKE SR. COTA/L
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
1224Z00000XOccupational Therapy AssistantOTA10650FL

General Provider Information

NPI Number : 1891256277
Entity Type Code : Individual
Provider Name (Legal Business Name) : RUSSELL LAMAR LOCKE SR. COTA/L
Provider Business Mailing Address
First Line : 6511 JUNE DR
Second Line :
City : COCOA
State : FL
Zip : 32926-2326
Country : US
Telephone Number : 321-333-2068
Fax Number : 321-877-1027
Provider Business Practice Location Address
First Line : 1705 JESS PARRISH CT
Second Line :
City : TITUSVILLE
State : FL
Zip : 32796-2158
Country : US
Telephone Number : 321-269-5720
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/27/2019
Last Update Date : 03/27/2019

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