Healthcare Provider Details

I. General information

NPI: 1013269299
Provider Name (Legal Business Name): MELISSA DOLORES MCDIVITT COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 FRANCES MEEKS WAY
RICHMOND HILL GA
31324-3983
US

IV. Provider business mailing address

977 BIRCHFIELD DR
HINESVILLE GA
31313-6478
US

V. Phone/Fax

Practice location:
  • Phone: 912-727-2321
  • Fax:
Mailing address:
  • Phone: 321-480-1274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA001464
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: