Healthcare Provider Details

I. General information

NPI: 1962687301
Provider Name (Legal Business Name): MICHAEL SCOTT SHELTON COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 BROKEN SOUND PKWY STE 500
BOCA RATON FL
33487-2791
US

IV. Provider business mailing address

1970 CEDAR GRAVEYARD RD
LEWISBURG KY
42256-8529
US

V. Phone/Fax

Practice location:
  • Phone: 561-367-1175
  • Fax:
Mailing address:
  • Phone: 270-535-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberKY-A3203
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: