Provider Demographics
NPI:1508449836
Name:CANTU, JULISSA (COTA)
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:CANTU
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 1:1904 ROSALINDA ST
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-6412
Mailing Address - Country:US
Mailing Address - Phone:956-454-0909
Mailing Address - Fax:
Practice Address - Street 1:1904 ROSALINDA ST
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6412
Practice Address - Country:US
Practice Address - Phone:956-454-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216773224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant