Provider Demographics
NPI:1770233033
Name:LOPEZ, ILIANA MICHELLE (COTA)
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:MICHELLE
Last Name:LOPEZ
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 1:310 W 64TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2670
Mailing Address - Country:US
Mailing Address - Phone:786-527-0651
Mailing Address - Fax:
Practice Address - Street 1:1140 W 50TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3440
Practice Address - Country:US
Practice Address - Phone:305-231-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18822224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant