Healthcare Provider Details

I. General information

NPI: 1356987051
Provider Name (Legal Business Name): GRETCHEN BLAHNIK COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

IV. Provider business mailing address

6190 BARNES RD
COLORADO SPRINGS CO
80922-2600
US

V. Phone/Fax

Practice location:
  • Phone: 855-407-7575
  • Fax:
Mailing address:
  • Phone: 719-597-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202008498
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: