Provider Demographics
NPI:1386085207
Name:CAVAZOS, JILL MAREE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:MAREE
Last Name:CAVAZOS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:MAREE
Other - Last Name:HARWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4703
Mailing Address - Country:US
Mailing Address - Phone:616-990-4760
Mailing Address - Fax:
Practice Address - Street 1:30 W 22ND ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4703
Practice Address - Country:US
Practice Address - Phone:616-990-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007658224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant