Provider Demographics
NPI:1881266096
Name:SANTOS, ALYSA MARI (COTA)
Entity type:Individual
Prefix:
First Name:ALYSA
Middle Name:MARI
Last Name:SANTOS
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 1:113 S FERRIS ST
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-8342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 S FERRIS ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-8342
Practice Address - Country:US
Practice Address - Phone:972-825-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216926224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant