Healthcare Provider Details

I. General information

NPI: 1699274407
Provider Name (Legal Business Name): ELIZABETH WILLIS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E HARMONT DR
PHOENIX AZ
85020-3864
US

IV. Provider business mailing address

8026 W CORRINE DR
PEORIA AZ
85381-9034
US

V. Phone/Fax

Practice location:
  • Phone: 602-331-1470
  • Fax:
Mailing address:
  • Phone: 509-995-5232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number7177
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: