Healthcare Provider Details

I. General information

NPI: 1770047763
Provider Name (Legal Business Name): SAMUEL TRENARY COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7355 E FURNACE BRANCH RD
GLEN BURNIE MD
21060-7060
US

IV. Provider business mailing address

30845 WARD RD
SALISBURY MD
21804-2753
US

V. Phone/Fax

Practice location:
  • Phone: 410-766-3460
  • Fax:
Mailing address:
  • Phone: 410-713-8745
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number16944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: