Provider Demographics
NPI:1447684568
Name:PENA, ANDRIK (COTA)
Entity type:Individual
Prefix:
First Name:ANDRIK
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6215 W 20TH AVE APT 214
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6063
Mailing Address - Country:US
Mailing Address - Phone:305-821-8972
Mailing Address - Fax:
Practice Address - Street 1:6215 W 20TH AVE APT 214
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6063
Practice Address - Country:US
Practice Address - Phone:305-821-8972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12320224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant