Healthcare Provider Details

I. General information

NPI: 1326390774
Provider Name (Legal Business Name): DAWN L CALLAHAN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S L ST
RICHMOND IN
47374-7439
US

IV. Provider business mailing address

3658 N JACKSONBURG RD
GREENS FORK IN
47345-9743
US

V. Phone/Fax

Practice location:
  • Phone: 765-966-5705
  • Fax:
Mailing address:
  • Phone: 765-977-4447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001571A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: