Healthcare Provider Details

I. General information

NPI: 1801202882
Provider Name (Legal Business Name): ERIN KELLIE JEFFRESS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 11/27/2023
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 N ROCK RD, BUILDING 2200, STE 101
WICHITA KS
67226
US

IV. Provider business mailing address

731 N KLEIN CIR
DERBY KS
67037-7011
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-3316
  • Fax:
Mailing address:
  • Phone: 316-440-9617
  • Fax: 316-440-9619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number18-00781
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: