Healthcare Provider Details

I. General information

NPI: 1346649688
Provider Name (Legal Business Name): HEATHER CARROLL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER WARRELL COTA

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E CLEVELAND RD
GRANGER IN
46530-5624
US

IV. Provider business mailing address

19839 DICE ST
SOUTH BEND IN
46614-5513
US

V. Phone/Fax

Practice location:
  • Phone: 574-271-3305
  • Fax:
Mailing address:
  • Phone: 574-217-2213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier32001597A
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerCOTA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: