Provider Demographics
NPI:1225571359
Name:MOGOLLON, CRISTHIAN E (OTA)
Entity Type:Individual
Prefix:
First Name:CRISTHIAN
Middle Name:E
Last Name:MOGOLLON
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13590 SW 134TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4575
Mailing Address - Country:US
Mailing Address - Phone:786-732-6646
Mailing Address - Fax:786-842-3218
Practice Address - Street 1:13590 SW 134TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4575
Practice Address - Country:US
Practice Address - Phone:786-732-6646
Practice Address - Fax:786-842-3218
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14121224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant