Healthcare Provider Details

I. General information

NPI: 1437372505
Provider Name (Legal Business Name): CHRISTINE RACHELLE EATON COTA DTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 LAKE AVE
PLYMOUTH IN
46563
US

IV. Provider business mailing address

1915 LAKE AVE
PLYMOUTH IN
46563
US

V. Phone/Fax

Practice location:
  • Phone: 574-935-2211
  • Fax: 574-935-2212
Mailing address:
  • Phone: 574-935-2211
  • Fax: 574-935-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001066A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: