Provider Demographics
NPI:1982811279
Name:DOUGLAS, MILES C (COTA)
Entity type:Individual
Prefix:
First Name:MILES
Middle Name:C
Last Name:DOUGLAS
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 1:357 CHEVELLE DR.
Mailing Address - Street 2:
Mailing Address - City:WEST MELBORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904
Mailing Address - Country:US
Mailing Address - Phone:321-271-1744
Mailing Address - Fax:
Practice Address - Street 1:1855 SANFORD CIR.
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234
Practice Address - Country:US
Practice Address - Phone:321-271-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10288224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant