Provider Demographics
NPI:1407493554
Name:MIFSUD, MICHAEL (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MIFSUD
Suffix:
Gender:M
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 1:520 WICKHAM LAKES DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2216
Mailing Address - Country:US
Mailing Address - Phone:321-243-4605
Mailing Address - Fax:
Practice Address - Street 1:1535 COGSWELL ST STE C24
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2740
Practice Address - Country:US
Practice Address - Phone:321-872-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17299224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant