Provider Demographics
NPI:1174255277
Name:MBATA, EZINNE (COTA)
Entity Type:Individual
Prefix:
First Name:EZINNE
Middle Name:
Last Name:MBATA
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 1:8410 BUSTLETON AVE APT G18
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-1917
Mailing Address - Country:US
Mailing Address - Phone:215-554-7125
Mailing Address - Fax:
Practice Address - Street 1:8410 BUSTLETON AVE APT G18
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-1917
Practice Address - Country:US
Practice Address - Phone:215-554-7125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP008368224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant