Provider Demographics
NPI:1821338633
Name:LILES, LONNIE (COTA)
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:
Last Name:LILES
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 1:8075 DELAROCHE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2408
Mailing Address - Country:US
Mailing Address - Phone:352-281-3834
Mailing Address - Fax:
Practice Address - Street 1:8075 DELAROCHE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:352-281-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12434224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant