Provider Demographics
NPI:1013520725
Name:BENTIVENGO, TALIA M (COTA)
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:M
Last Name:BENTIVENGO
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 1:28991 OLD TOWN FRONT ST STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2858
Mailing Address - Country:US
Mailing Address - Phone:951-556-8157
Mailing Address - Fax:951-414-6060
Practice Address - Street 1:28991 OLD TOWN FRONT ST STE 101
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2858
Practice Address - Country:US
Practice Address - Phone:951-556-8157
Practice Address - Fax:951-414-6060
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5358224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant