Provider Demographics
NPI:1760670301
Name:AYALA, HERNAN (COTA)
Entity Type:Individual
Prefix:MR
First Name:HERNAN
Middle Name:
Last Name:AYALA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-5418
Mailing Address - Country:US
Mailing Address - Phone:718-476-9092
Mailing Address - Fax:
Practice Address - Street 1:5821 84TH ST
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-5418
Practice Address - Country:US
Practice Address - Phone:718-476-9092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant