Healthcare Provider Details

I. General information

NPI: 1700115193
Provider Name (Legal Business Name): KIMBERLY REENEE BAKER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 BROADBENT RD
LANSING MI
48917-9706
US

IV. Provider business mailing address

708 DENVER ST
LANSING MI
48910-6417
US

V. Phone/Fax

Practice location:
  • Phone: 517-731-6200
  • Fax:
Mailing address:
  • Phone: 207-242-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOA2315
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001741A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202008121
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: