Healthcare Provider Details

I. General information

NPI: 1043431075
Provider Name (Legal Business Name): PAMELA S WICKE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 STATE ST
FRANKLIN IN
46131-2552
US

IV. Provider business mailing address

220 ARDMOOR DR
WHITELAND IN
46184-1432
US

V. Phone/Fax

Practice location:
  • Phone: 317-736-6414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32000189A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: