Provider Demographics
NPI:1952017303
Name:DELLATORE, VIRGINIA LOUISE (COTA)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LOUISE
Last Name:DELLATORE
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 1:3670 DIXIE HWY NE LOT 30
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2741
Mailing Address - Country:US
Mailing Address - Phone:772-321-9245
Mailing Address - Fax:
Practice Address - Street 1:3670 DIXIE HWY NE LOT 30
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2741
Practice Address - Country:US
Practice Address - Phone:772-321-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14856224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant