Healthcare Provider Details

I. General information

NPI: 1669814778
Provider Name (Legal Business Name): RAYMOND A SMITH COTA, SWT, CADC-M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MEMORIAL RD
HOUGHTON MI
49931-2475
US

IV. Provider business mailing address

901 MEMORIAL RD
HOUGHTON MI
49931-2475
US

V. Phone/Fax

Practice location:
  • Phone: 906-482-9400
  • Fax:
Mailing address:
  • Phone: 906-482-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1-04119
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6803082583
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202005476
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: