Provider Demographics
NPI:1659792893
Name:MIJARES, DEBRA (COTA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:MIJARES
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 1:890 GOVERNOR ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3342
Mailing Address - Country:US
Mailing Address - Phone:949-645-9881
Mailing Address - Fax:
Practice Address - Street 1:330 GOLDEN SHR
Practice Address - Street 2:SUITE 250
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4246
Practice Address - Country:US
Practice Address - Phone:866-414-0448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA827224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant