MEDICARE: MRS. TARA STCLAIR COTA

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	208382	TX

General Provider Information

NPI Number	:	1790266211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA STCLAIR COTA

Provider Business Mailing Address
First Line	:	3210 W HIGHWAY 22
Second Line	:
City	:	CORSICANA
State	:	TX
Zip	:	75110-2449
Country	:	US
Telephone Number	:	903-872-4880
Fax Number	:	903-641-0391

Provider Business Practice Location Address
First Line	:	3210 W HIGHWAY 22
Second Line	:
City	:	CORSICANA
State	:	TX
Zip	:	75110-2449
Country	:	US
Telephone Number	:	903-872-4880
Fax Number	:	903-641-0391

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

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	08/23/2018

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