Provider Demographics
NPI:1699094185
Name:ANDERSON, ATHLENE MARIE (COTA)
Entity type:Individual
Prefix:
First Name:ATHLENE
Middle Name:MARIE
Last Name:ANDERSON
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 1:8220 SW 22ND ST
Mailing Address - Street 2:APT. # 107
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-5049
Mailing Address - Country:US
Mailing Address - Phone:954-934-2964
Mailing Address - Fax:
Practice Address - Street 1:6152 VERDE TRL N
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-2430
Practice Address - Country:US
Practice Address - Phone:561-852-4173
Practice Address - Fax:561-852-4956
Is Sole Proprietor?:No
Enumeration Date:2010-05-23
Last Update Date:2010-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11055224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant