Provider Demographics
NPI:1609584515
Name:DOUGLASS, EDWIN IV (COTA/L)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:DOUGLASS
Suffix:IV
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 1:6200 MAHAFFEY RD UNIT 106
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1646
Mailing Address - Country:US
Mailing Address - Phone:716-609-4072
Mailing Address - Fax:
Practice Address - Street 1:2629 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5769
Practice Address - Country:US
Practice Address - Phone:239-574-4434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA19164224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant