Healthcare Provider Details

I. General information

NPI: 1154679504
Provider Name (Legal Business Name): HEATHER CHRISTINE JOHNSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 GALTIER ST
SAINT PAUL MN
55103-2358
US

IV. Provider business mailing address

9231 16TH AVE S
BLOOMINGTON MN
55425-2305
US

V. Phone/Fax

Practice location:
  • Phone: 651-224-1848
  • Fax:
Mailing address:
  • Phone: 612-414-5825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number201700
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: