Healthcare Provider Details

I. General information

NPI: 1356633291
Provider Name (Legal Business Name): VICKIE LEE FALLIS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 MITCHELL AVE
BATESVILLE IN
47006-8909
US

IV. Provider business mailing address

321 MITCHELL AVE
BATESVILLE IN
47006-8909
US

V. Phone/Fax

Practice location:
  • Phone: 812-934-6624
  • Fax: 812-934-6219
Mailing address:
  • Phone: 812-934-6624
  • Fax: 812-934-6219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number320000193A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: