Provider Demographics
NPI:1043564008
Name:TELLEZ, JORGE L (COTA,L)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:COTA,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 INDUSTRIAL PARK ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06455-1263
Mailing Address - Country:US
Mailing Address - Phone:203-859-1182
Mailing Address - Fax:
Practice Address - Street 1:145 GROVE ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-2202
Practice Address - Country:US
Practice Address - Phone:203-753-7205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001138224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant