Healthcare Provider Details

I. General information

NPI: 1306253885
Provider Name (Legal Business Name): JEFFERY RANSOM FREEMAN COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 OAKMAN BLVD
DETROIT MI
48238-3710
US

IV. Provider business mailing address

9854 COLWELL AVE
ALLEN PARK MI
48101-1315
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-4890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224ZE0001X
TaxonomyEnvironmental Modification Occupational Therapy Assistant
License Number5202007521
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: