Healthcare Provider Details

I. General information

NPI: 1831737675
Provider Name (Legal Business Name): JEANINE SPURLEY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JEANINE THOMMEN

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 MALLERY DR
LANHAM MD
20706-3964
US

IV. Provider business mailing address

7359 RIDGEWATER CT APT 201
GLEN BURNIE MD
21060-7498
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-2000
  • Fax:
Mailing address:
  • Phone: 410-847-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA02847
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: