Provider Demographics
NPI:1487284626
Name:BRACETTY- FUENTES, DIANA (COTA/L)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BRACETTY- FUENTES
Suffix:
Gender:F
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 1:15029 ISLAND BAY DRIVE APT 104
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828
Mailing Address - Country:US
Mailing Address - Phone:413-240-8428
Mailing Address - Fax:
Practice Address - Street 1:15029 ISLAND BAY DR APT 104
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9460
Practice Address - Country:US
Practice Address - Phone:413-240-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA17596224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant