Provider Demographics
NPI:1811645674
Name:RANDALL, ANGELICA TERESA (COTA)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:TERESA
Last Name:RANDALL
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 1:2651 S 8TH AVE APT 2037
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7196
Mailing Address - Country:US
Mailing Address - Phone:860-459-9968
Mailing Address - Fax:
Practice Address - Street 1:450 W 6TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2973
Practice Address - Country:US
Practice Address - Phone:860-459-9968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOT-046802224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant