Healthcare Provider Details

I. General information

NPI: 1437447828
Provider Name (Legal Business Name): KELLIE OLIVER SCOTT COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 GANDY ST NE
RUSSELLVILLE AL
35653-1913
US

IV. Provider business mailing address

724 GRAVEL HILL RD
PHIL CAMPBELL AL
35581-4304
US

V. Phone/Fax

Practice location:
  • Phone: 256-332-1611
  • Fax:
Mailing address:
  • Phone: 256-436-1706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3197
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: