Provider Demographics
NPI:1821534108
Name:WILLS, TINA A (COTA)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:A
Last Name:WILLS
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 1:347 MYRTLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7768
Mailing Address - Country:US
Mailing Address - Phone:321-626-4970
Mailing Address - Fax:
Practice Address - Street 1:347 MYRTLEWOOD RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7768
Practice Address - Country:US
Practice Address - Phone:321-626-4970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 15363224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant