Healthcare Provider Details

I. General information

NPI: 1053682237
Provider Name (Legal Business Name): SHANA WELCH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 OLD STRONG HWY
STRONG AR
71765
US

IV. Provider business mailing address

1700 OLD STRONG HWY
STRONG AR
71765-9507
US

V. Phone/Fax

Practice location:
  • Phone: 870-797-3089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A674
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: