Provider Demographics
NPI:1417476896
Name:PARK, LAUREN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:PARK
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 1:2989 MIKRIS DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-7624
Mailing Address - Country:US
Mailing Address - Phone:217-620-8355
Mailing Address - Fax:
Practice Address - Street 1:235 9TH AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-7142
Practice Address - Country:US
Practice Address - Phone:904-249-8893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-17
Last Update Date:2017-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16115224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant