Provider Demographics
NPI:1104045608
Name:HERNANDEZ, DOROTHY ALICE (COTA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ALICE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64504-1535
Mailing Address - Country:US
Mailing Address - Phone:816-238-4618
Mailing Address - Fax:
Practice Address - Street 1:1202 HEARTLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3492
Practice Address - Country:US
Practice Address - Phone:816-671-8506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004052224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant