Provider Demographics
NPI:1528304466
Name:MOLINA, MIRANDA MARY (COTA)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:MARY
Last Name:MOLINA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:771 SIESTA KEY TRL
Mailing Address - Street 2:APT 1017
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-7778
Mailing Address - Country:US
Mailing Address - Phone:954-629-5085
Mailing Address - Fax:
Practice Address - Street 1:7451 WILES RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-2040
Practice Address - Country:US
Practice Address - Phone:954-840-0556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 12513224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant