Provider Demographics
NPI:1609384635
Name:MANJARRES, LINA MARIA (COTA/L)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:MARIA
Last Name:MANJARRES
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 1:501 SE 2ND ST APT 514
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3672
Mailing Address - Country:US
Mailing Address - Phone:786-603-3025
Mailing Address - Fax:
Practice Address - Street 1:14201 W SUNRISE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-3207
Practice Address - Country:US
Practice Address - Phone:954-756-2818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16292224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant