Healthcare Provider Details

I. General information

NPI: 1952781858
Provider Name (Legal Business Name): CANDACE MILES COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7734 MACEDONIA RD
HOULKA MS
38850-7327
US

IV. Provider business mailing address

7734 MACEDONIA RD
HOULKA MS
38850-7327
US

V. Phone/Fax

Practice location:
  • Phone: 662-568-2079
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA2922
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: