Healthcare Provider Details

I. General information

NPI: 1871994186
Provider Name (Legal Business Name): KELLY HEYSE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2014
Last Update Date: 09/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E TINKHAM AVE
LUDINGTON MI
49431-1568
US

IV. Provider business mailing address

1000 E TINKHAM AVE
LUDINGTON MI
49431-1568
US

V. Phone/Fax

Practice location:
  • Phone: 231-845-6291
  • Fax: 231-843-4121
Mailing address:
  • Phone: 231-845-6291
  • Fax: 231-843-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202005019
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: