Healthcare Provider Details

I. General information

NPI: 1750636551
Provider Name (Legal Business Name): HOLLY JO PRUETT COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHARLEVOIX DR SE SUITE 200
GRAND RAPIDS MI
49546-7085
US

IV. Provider business mailing address

2900 CHARLEVOIX DR SE SUITE 200
GRAND RAPIDS MI
49546-7085
US

V. Phone/Fax

Practice location:
  • Phone: 180-063-4107
  • Fax: 616-975-5030
Mailing address:
  • Phone: 180-063-4107
  • Fax: 616-975-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: