Healthcare Provider Details

I. General information

NPI: 1538823745
Provider Name (Legal Business Name): VIOLA FAYE BERTRAM COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARK ST E
ANNANDALE MN
55302-3060
US

IV. Provider business mailing address

1316 ELIZABETH AVE
WILLMAR MN
56201-3737
US

V. Phone/Fax

Practice location:
  • Phone: 320-274-2394
  • Fax:
Mailing address:
  • Phone: 320-979-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number201488
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: