Provider Demographics
NPI:1912720962
Name:BURGOS, LILY ROSE (COTA)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:ROSE
Last Name:BURGOS
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 1:3240 POE DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-5500
Mailing Address - Country:US
Mailing Address - Phone:832-931-3545
Mailing Address - Fax:
Practice Address - Street 1:25018 OAKHURST DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-2722
Practice Address - Country:US
Practice Address - Phone:888-364-9695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218090224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant