Provider Demographics
NPI:1942746813
Name:PENA, EDWARD AYANIS (COTA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:AYANIS
Last Name:PENA
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 1:3216 RESERVE CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7180
Mailing Address - Country:US
Mailing Address - Phone:407-300-0799
Mailing Address - Fax:
Practice Address - Street 1:1252 S JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-6319
Practice Address - Country:US
Practice Address - Phone:407-913-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15701224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant