Healthcare Provider Details

I. General information

NPI: 1518580190
Provider Name (Legal Business Name): MIKAYLIN SHAY COLLETTE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 NW 7TH ST
BENTONVILLE AR
72712-4565
US

IV. Provider business mailing address

109 FAWN TRL
SENECA MO
64865-8551
US

V. Phone/Fax

Practice location:
  • Phone: 479-250-9838
  • Fax:
Mailing address:
  • Phone: 417-389-6483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1620
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: