Provider Demographics
NPI:1609562024
Name:OLIVAS-GOMEZ, ENRIQUE ARMANDO (COTA)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:ARMANDO
Last Name:OLIVAS-GOMEZ
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 1:6811 DELTA DR SPC 211NA
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-5515
Mailing Address - Country:US
Mailing Address - Phone:915-222-4153
Mailing Address - Fax:
Practice Address - Street 1:1575 BELVIDERE ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-2649
Practice Address - Country:US
Practice Address - Phone:915-833-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214397224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant