Provider Demographics
NPI:1396365847
Name:SANTOS FLORES, LISSANDRA D (COTA/L)
Entity Type:Individual
Prefix:
First Name:LISSANDRA
Middle Name:D
Last Name:SANTOS FLORES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8106 BRICKLETON WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5700
Mailing Address - Country:US
Mailing Address - Phone:623-888-2804
Mailing Address - Fax:
Practice Address - Street 1:202 AVENUE O NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2409
Practice Address - Country:US
Practice Address - Phone:863-293-3103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA17668224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9513999637Medicaid