Healthcare Provider Details

I. General information

NPI: 1326602046
Provider Name (Legal Business Name): KRISTIN WURTENBERGER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 CHESTNUT STATION CT
LOUISVILLE KY
40299-6395
US

IV. Provider business mailing address

1601 GIRARD DR
LOUISVILLE KY
40222-6666
US

V. Phone/Fax

Practice location:
  • Phone: 800-335-1060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number167949
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: