Provider Demographics
NPI:1194107037
Name:SIERRA, ENRIQUE (COTA/L)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:SIERRA
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 1:199 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-1637
Mailing Address - Country:US
Mailing Address - Phone:407-314-7058
Mailing Address - Fax:
Practice Address - Street 1:199 PARK ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1637
Practice Address - Country:US
Practice Address - Phone:407-314-7058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-27
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03237158224Z00000X
FLOTA11654224Z00000X
NJ46TA09096000224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant