Provider Demographics
NPI:1104597814
Name:LOLLEY, ASHTEN MIKAELA (COTA/L)
Entity type:Individual
Prefix:
First Name:ASHTEN
Middle Name:MIKAELA
Last Name:LOLLEY
Suffix:
Gender:F
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 1:1532 LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:APALACHICOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32320-1363
Mailing Address - Country:US
Mailing Address - Phone:850-340-3550
Mailing Address - Fax:
Practice Address - Street 1:305 MACK BAYOU RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7199
Practice Address - Country:US
Practice Address - Phone:850-213-4595
Practice Address - Fax:850-213-4596
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18487224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant