Provider Demographics
NPI:1154803658
Name:PETERS, PAULA JAN (COTA)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:JAN
Last Name:PETERS
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 1:526 TRAILBLAZER RD
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-4732
Mailing Address - Country:US
Mailing Address - Phone:214-284-3071
Mailing Address - Fax:
Practice Address - Street 1:505 W CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5445
Practice Address - Country:US
Practice Address - Phone:972-840-0970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212455224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant