Healthcare Provider Details

I. General information

NPI: 1184188435
Provider Name (Legal Business Name): KENNETH CHARLES DEAN COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8924 BAYONNE DR
SHREVEPORT LA
71118-2033
US

IV. Provider business mailing address

127 W BROAD ST
LAKE CHARLES LA
70601-4393
US

V. Phone/Fax

Practice location:
  • Phone: 318-294-1952
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number214817
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: