Healthcare Provider Details

I. General information

NPI: 1942639679
Provider Name (Legal Business Name): ASHLEY GRAUVOGL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 CAMPBELL ST
VALPARAISO IN
46385-2363
US

IV. Provider business mailing address

1711 CEDAR ST
VALPARAISO IN
46383-4303
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-1023
  • Fax:
Mailing address:
  • Phone: 219-689-1393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32002051A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057003456
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: