Healthcare Provider Details

I. General information

NPI: 1598471955
Provider Name (Legal Business Name): SAMANTHA VERMILLION COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29800 HOOVER RD
WARREN MI
48093-8918
US

IV. Provider business mailing address

29322 ROSEBRIAR ST
SAINT CLAIR SHORES MI
48081-3038
US

V. Phone/Fax

Practice location:
  • Phone: 586-574-3444
  • Fax:
Mailing address:
  • Phone: 586-524-7153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202007943
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: