Provider Demographics
NPI:1225730393
Name:PEDRAZA ROGER, MARILEN (COTA)
Entity Type:Individual
Prefix:
First Name:MARILEN
Middle Name:
Last Name:PEDRAZA ROGER
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 1:3821 WINGWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-7734
Mailing Address - Country:US
Mailing Address - Phone:407-748-7424
Mailing Address - Fax:
Practice Address - Street 1:4303 VINELAND RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-7176
Practice Address - Country:US
Practice Address - Phone:407-499-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19385225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation