Provider Demographics
NPI:1902133234
Name:FERNANDEZ, GREGORY DOMINIC (COTA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DOMINIC
Last Name:FERNANDEZ
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 1:3225 MAUMELLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-1319
Mailing Address - Country:US
Mailing Address - Phone:469-467-3949
Mailing Address - Fax:
Practice Address - Street 1:1000 US HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-1704
Practice Address - Country:US
Practice Address - Phone:903-893-9636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210616224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant