Healthcare Provider Details

I. General information

NPI: 1053755157
Provider Name (Legal Business Name): MANUELA LINDSEY COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 W CREIGHTON AVE
FORT WAYNE IN
46807-1330
US

IV. Provider business mailing address

336 W CREIGHTON AVE
FORT WAYNE IN
46807-1330
US

V. Phone/Fax

Practice location:
  • Phone: 260-442-4556
  • Fax:
Mailing address:
  • Phone: 260-442-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32002354A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number212056
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: