Provider Demographics
NPI:1124662333
Name:WILLETT, ANGELICA ELAINE (COTA)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:ELAINE
Last Name:WILLETT
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 1:4450 W EAU GALLIE BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7277
Mailing Address - Country:US
Mailing Address - Phone:321-255-6627
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD STE 180
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7277
Practice Address - Country:US
Practice Address - Phone:321-255-6627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17267224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant