Healthcare Provider Details

I. General information

NPI: 1225754856
Provider Name (Legal Business Name): ELISA MARIE KABELIS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 DICKINSON RD
CHESTERTON IN
46304-3540
US

IV. Provider business mailing address

486 MEADOWWOOD DR
VALPARAISO IN
46385-9029
US

V. Phone/Fax

Practice location:
  • Phone: 219-983-1300
  • Fax:
Mailing address:
  • Phone: 219-381-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32000328A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: