Provider Demographics
NPI:1720544893
Name:PADILLA, MAYRA (COTA/L)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:PADILLA
Suffix:
Gender:F
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 1:1531 REFLECTION CV
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-7510
Mailing Address - Country:US
Mailing Address - Phone:321-443-0983
Mailing Address - Fax:
Practice Address - Street 1:202 AVENUE O NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2499
Practice Address - Country:US
Practice Address - Phone:863-293-3103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16846224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant