Provider Demographics
NPI:1952866261
Name:BAEZA, LUIS S (COTA)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:S
Last Name:BAEZA
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 1:365 LA PUESTA DR APT 271
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-8513
Mailing Address - Country:US
Mailing Address - Phone:915-207-4869
Mailing Address - Fax:
Practice Address - Street 1:10880 EDGEMERE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-1306
Practice Address - Country:US
Practice Address - Phone:915-590-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210926224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty