Provider Demographics
NPI:1639571946
Name:JOLLEY, MARLO (COTA)
Entity Type:Individual
Prefix:MS
First Name:MARLO
Middle Name:
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9430 LIVE OAK PL
Mailing Address - Street 2:#405
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-4763
Mailing Address - Country:US
Mailing Address - Phone:954-505-1937
Mailing Address - Fax:
Practice Address - Street 1:9430 LIVE OAK PLACE
Practice Address - Street 2:#405
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33326-6706
Practice Address - Country:US
Practice Address - Phone:954-505-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL329372224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant