Provider Demographics
NPI:1982350211
Name:JUAREZ, BENITO ALBERTO (COTA/L)
Entity Type:Individual
Prefix:
First Name:BENITO
Middle Name:ALBERTO
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 COUNTY ROAD 12
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-9642
Mailing Address - Country:US
Mailing Address - Phone:419-355-5452
Mailing Address - Fax:
Practice Address - Street 1:410 FAIR LN
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2518
Practice Address - Country:US
Practice Address - Phone:567-938-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA002285224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant