Healthcare Provider Details

I. General information

NPI: 1063756146
Provider Name (Legal Business Name): LISE KETTERER COTA. NHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA CLOUD

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/27/2023
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 KITTYHAWK RD
COLORADO SPRINGS CO
80920-1441
US

IV. Provider business mailing address

3578 HARTSEL DR # E-335
COLORADO SPRINGS CO
80920-2103
US

V. Phone/Fax

Practice location:
  • Phone: 949-813-8637
  • Fax:
Mailing address:
  • Phone: 949-813-8637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.0000024
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2214
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberNHA.0002857
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: