Provider Demographics
NPI:1629651914
Name:ACOSTA, RAUL IVAN (OTR)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:IVAN
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LAKEVIEW DR APT 202
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2518
Mailing Address - Country:US
Mailing Address - Phone:305-879-3436
Mailing Address - Fax:
Practice Address - Street 1:5190 NW 167TH ST STE 304
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6338
Practice Address - Country:US
Practice Address - Phone:305-756-9947
Practice Address - Fax:305-756-9948
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT21796225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist