Healthcare Provider Details

I. General information

NPI: 1356999817
Provider Name (Legal Business Name): MICHELLE SUE GRAUN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 87TH AVE
MERRILLVILLE IN
46410-6177
US

IV. Provider business mailing address

101 W 87TH AVE
MERRILLVILLE IN
46410-6177
US

V. Phone/Fax

Practice location:
  • Phone: 219-756-0744
  • Fax:
Mailing address:
  • Phone: 219-756-0744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001919A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: