Healthcare Provider Details

I. General information

NPI: 1104383892
Provider Name (Legal Business Name): FAITH WHITEHEAD COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 NE 7TH ST # 463-7101
TRENTON FL
32693-3636
US

IV. Provider business mailing address

427 SW 4TH AVE
TRENTON FL
32693-4246
US

V. Phone/Fax

Practice location:
  • Phone: 352-463-7101
  • Fax:
Mailing address:
  • Phone: 818-220-6405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA17053
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: