Provider Demographics
NPI:1952846131
Name:MOGOLLON OLIVERA, LORETA (COTA/L)
Entity Type:Individual
Prefix:
First Name:LORETA
Middle Name:
Last Name:MOGOLLON OLIVERA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13590 SW 134TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4575
Mailing Address - Country:US
Mailing Address - Phone:786-732-6646
Mailing Address - Fax:786-842-3218
Practice Address - Street 1:13590 SW 134TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4561
Practice Address - Country:US
Practice Address - Phone:786-732-6646
Practice Address - Fax:786-842-3218
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11333224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA 11333OtherDOH