Provider Demographics
NPI:1124680574
Name:GARLAND, DOMINQUE L (COTA)
Entity type:Individual
Prefix:
First Name:DOMINQUE
Middle Name:L
Last Name:GARLAND
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 MYRTLE LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-6568
Mailing Address - Country:US
Mailing Address - Phone:352-630-1358
Mailing Address - Fax:
Practice Address - Street 1:606 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6320
Practice Address - Country:US
Practice Address - Phone:352-630-1358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-07
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16857224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant