Healthcare Provider Details

I. General information

NPI: 1598009771
Provider Name (Legal Business Name): JASON ERIC WYLIE COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12803 LENOVER ST
DILLSBORO IN
47018-9418
US

IV. Provider business mailing address

510B PEARL ST
VEVAY IN
47043-8414
US

V. Phone/Fax

Practice location:
  • Phone: 812-432-5226
  • Fax:
Mailing address:
  • Phone: 812-801-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32002153A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: