Provider Demographics
NPI:1770815813
Name:LARA, MARITZA (COTA, LMT)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:COTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 SW 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-5506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1031 SW 109TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-5506
Practice Address - Country:US
Practice Address - Phone:786-356-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-30
Last Update Date:2010-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11093224Z00000X
FLMA35505225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist