MEDICARE: JEANINE BROCK 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
1	224Z00000X	Occupational Therapy Assistant	OTA16397	FL

General Provider Information

NPI Number	:	1992484000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANINE BROCK COTA/L

Provider Business Mailing Address
First Line	:	2471 16TH AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33713-5627
Country	:	US
Telephone Number	:	727-303-5140
Fax Number	:

Provider Business Practice Location Address
First Line	:	2471 16TH AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33713-5627
Country	:	US
Telephone Number	:	727-303-5140
Fax Number	:

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

Provider Enumeration Date	:	07/17/2023
Last Update Date	:	07/17/2023

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