Provider Demographics
NPI:1598354573
Name:ROBLEDO, EDNA ITZEL (COTA/L)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:ITZEL
Last Name:ROBLEDO
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 1:3137 SPYGLASS DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7508
Mailing Address - Country:US
Mailing Address - Phone:469-422-5803
Mailing Address - Fax:
Practice Address - Street 1:3137 SPYGLASS DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7508
Practice Address - Country:US
Practice Address - Phone:469-422-5803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216261224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant