Healthcare Provider Details

I. General information

NPI: 1518167386
Provider Name (Legal Business Name): BRENDA MARCH COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 FAIRFIELD ST
REVERE MA
02151-4516
US

IV. Provider business mailing address

21 FAIRFIELD ST
REVERE MA
02151-4516
US

V. Phone/Fax

Practice location:
  • Phone: 781-289-8535
  • Fax:
Mailing address:
  • Phone: 781-289-8535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2653
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number2653
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: