Healthcare Provider Details

I. General information

NPI: 1740688332
Provider Name (Legal Business Name): MISTY DAWN COLLINS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2014
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PHILLIPS BRANCH RD
PHELPS KY
41553-9061
US

IV. Provider business mailing address

60 PHILLIPS BRANCH RD
PHELPS KY
41553-9061
US

V. Phone/Fax

Practice location:
  • Phone: 606-456-8725
  • Fax:
Mailing address:
  • Phone: 606-456-8725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA4901
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: