Healthcare Provider Details

I. General information

NPI: 1417621913
Provider Name (Legal Business Name): CRYSTIE KATELYN HARBER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 FERNDALE APARTMENTS RD
PINEVILLE KY
40977-8578
US

IV. Provider business mailing address

2097 WARD HILL RD
PENNINGTON GAP VA
24277-8017
US

V. Phone/Fax

Practice location:
  • Phone: 606-337-7071
  • Fax:
Mailing address:
  • Phone: 276-207-3320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number271854
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: