Healthcare Provider Details

I. General information

NPI: 1083958458
Provider Name (Legal Business Name): SUSAN HARMENING COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2012
Last Update Date: 11/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 CARTER ST
RICHMOND HILL GA
31324-3753
US

IV. Provider business mailing address

4 KEEL PT
SAVANNAH GA
31419-9590
US

V. Phone/Fax

Practice location:
  • Phone: 912-756-6131
  • Fax: 912-756-6246
Mailing address:
  • Phone: 678-612-8553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number000683
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: