Healthcare Provider Details

I. General information

NPI: 1861637696
Provider Name (Legal Business Name): ADAM JOHN WILLIAMS COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2008
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14145 SIMONE DR
SHELBY TOWNSHIP MI
48315-3228
US

IV. Provider business mailing address

21807 BLACKBURN ST
SAINT CLAIR SHORES MI
48080-3901
US

V. Phone/Fax

Practice location:
  • Phone: 586-566-6280
  • Fax:
Mailing address:
  • Phone: 586-943-8074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202007083
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: