Provider Demographics
NPI:1598223257
Name:MAGNUSON, ERIK ALBERT (COTA)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:ALBERT
Last Name:MAGNUSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19208 BRIERCREST TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32833-5522
Mailing Address - Country:US
Mailing Address - Phone:321-695-5167
Mailing Address - Fax:
Practice Address - Street 1:19208 BRIERCREST TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32833-5522
Practice Address - Country:US
Practice Address - Phone:321-695-5167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15696224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant