Provider Demographics
NPI:1548605678
Name:GONZALES, JEREMY DAVID (COTA/L)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:GONZALES
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 1:289 MORNING GLORY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6100
Mailing Address - Country:US
Mailing Address - Phone:407-416-4867
Mailing Address - Fax:
Practice Address - Street 1:289 MORNING GLORY DR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6100
Practice Address - Country:US
Practice Address - Phone:407-416-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 10825224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant