Healthcare Provider Details

I. General information

NPI: 1548793573
Provider Name (Legal Business Name): TOSHIA DONYELLE SULLIVAN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 STUART NELSON PARK RD
PADUCAH KY
42001-9678
US

IV. Provider business mailing address

142 STUART NELSON PARK RD
PADUCAH KY
42001-9678
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-9502
  • Fax: 270-442-1954
Mailing address:
  • Phone: 270-442-9502
  • Fax: 270-442-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number137496
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: