Healthcare Provider Details

I. General information

NPI: 1104245695
Provider Name (Legal Business Name): FATEMA LYNN CISCHKE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 RIDGEDALE RD
SOUTH BEND IN
46614-2243
US

IV. Provider business mailing address

55196 HOLMES RD
SOUTH BEND IN
46628-4912
US

V. Phone/Fax

Practice location:
  • Phone: 574-291-6722
  • Fax: 574-291-8768
Mailing address:
  • Phone: 574-310-9198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001532A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: