Provider Demographics
NPI:1447036462
Name:EISELE, MIA (COTA)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:EISELE
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 1:20525 CYPRESSWOOD DR APT 8204
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-4709
Mailing Address - Country:US
Mailing Address - Phone:815-355-8599
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?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218009224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant