Healthcare Provider Details

I. General information

NPI: 1609073873
Provider Name (Legal Business Name): CAROL J EARL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 LUTE RD
PORTAGE IN
46368-5008
US

IV. Provider business mailing address

4408 KINGSDALE DR
VALPARAISO IN
46383-1421
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-6858
  • Fax: 219-763-4858
Mailing address:
  • Phone: 219-462-0755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32000220A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: