Healthcare Provider Details

I. General information

NPI: 1568766186
Provider Name (Legal Business Name): JEANETTE WIDEBERG COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2010
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 DOCTOR AVE
SEBASTIAN FL
32958-4821
US

IV. Provider business mailing address

709 DOCTOR AVE
SEBASTIAN FL
32958-4821
US

V. Phone/Fax

Practice location:
  • Phone: 772-913-1517
  • Fax:
Mailing address:
  • Phone: 772-913-1517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA6186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: