Healthcare Provider Details

I. General information

NPI: 1417177080
Provider Name (Legal Business Name): DIANE C GARCIA COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 W APOLLO RD
PHOENIX AZ
85041-5339
US

IV. Provider business mailing address

18216 W SAN JUAN CT
LITCHFIELD PARK AZ
85340-8383
US

V. Phone/Fax

Practice location:
  • Phone: 520-271-6809
  • Fax: 602-305-7880
Mailing address:
  • Phone: 480-307-2173
  • Fax: 602-305-7880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1536
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: