Provider Demographics
NPI:1891128757
Name:GONZALES, SELENA LEA (COTA)
Entity Type:Individual
Prefix:MS
First Name:SELENA
Middle Name:LEA
Last Name:GONZALES
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 1:2611 JONES AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2650
Mailing Address - Country:US
Mailing Address - Phone:719-564-1735
Mailing Address - Fax:
Practice Address - Street 1:2611 JONES AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2650
Practice Address - Country:US
Practice Address - Phone:719-564-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1029143224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant