Healthcare Provider Details

I. General information

NPI: 1134764939
Provider Name (Legal Business Name): AMY BOSS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY DE HAAN COTA

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2110
  • Fax:
Mailing address:
  • Phone: 616-965-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202008750
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: