MEDICARE: KEJA MARIE CLARK COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	OTA-2678	NV

General Provider Information

NPI Number	:	1174198592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEJA MARIE CLARK COTA/L

Provider Business Mailing Address
First Line	:	901 JOSEPH KERWIN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-5944
Country	:	US
Telephone Number	:	702-918-3708
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 JOSEPH KERWIN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-5944
Country	:	US
Telephone Number	:	702-918-3708
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2021
Last Update Date	:	05/26/2021

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