Provider Demographics
NPI:1649693938
Name:CHACON CONTRERAS, MARY (COTA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:CHACON CONTRERAS
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 1:6921 NW 173RD DR APT 205
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5593
Mailing Address - Country:US
Mailing Address - Phone:603-557-7656
Mailing Address - Fax:
Practice Address - Street 1:6921 NW 173RD DR APT 205
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5593
Practice Address - Country:US
Practice Address - Phone:603-557-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OTA12769224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant