Healthcare Provider Details

I. General information

NPI: 1902221187
Provider Name (Legal Business Name): WENDI LAGORE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. WENDI YOUNG

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 TOMMY RATZLAFF AVE
GREEN FOREST AR
72638-2911
US

IV. Provider business mailing address

PO BOX 1950
GREEN FOREST AR
72638-1950
US

V. Phone/Fax

Practice location:
  • Phone: 870-438-5201
  • Fax: 870-438-6214
Mailing address:
  • Phone: 870-438-5201
  • Fax: 870-438-6214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2013033612
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: