Provider Demographics
NPI:1164084620
Name:FAVELA, EDWARD MARK JR (COTA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:MARK
Last Name:FAVELA
Suffix:JR
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 N ZARAGOZA RD STE B4
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-8041
Mailing Address - Country:US
Mailing Address - Phone:915-257-5782
Mailing Address - Fax:
Practice Address - Street 1:1514 N ZARAGOZA RD STE B4
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8041
Practice Address - Country:US
Practice Address - Phone:915-257-5782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008595224Z00000X
TX215683224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant