Healthcare Provider Details

I. General information

NPI: 1942597877
Provider Name (Legal Business Name): AMANDA M KEGG COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5202 SAINT JOE RD SUITE 340
FORT WAYNE IN
46835-3380
US

IV. Provider business mailing address

2620 KENWOOD AVE
FORT WAYNE IN
46805-2841
US

V. Phone/Fax

Practice location:
  • Phone: 260-485-6068
  • Fax:
Mailing address:
  • Phone: 260-241-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001579A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: