Healthcare Provider Details

I. General information

NPI: 1245739093
Provider Name (Legal Business Name): CHELSEA ALEXANDRA HERITAGE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11840 S LA CIENEGA BLVD
HAWTHORNE CA
90250
US

IV. Provider business mailing address

515 EDGEWOOD ST
INGLEWOOD CA
90302-3014
US

V. Phone/Fax

Practice location:
  • Phone: 424-269-3400
  • Fax: 310-882-5451
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: