Healthcare Provider Details

I. General information

NPI: 1497948889
Provider Name (Legal Business Name): AMANDA M BENNETT COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 NORTHTOWN DR SUITE 110 TRINITY REHAB
JACKSON MS
39211
US

IV. Provider business mailing address

PO BOX 315 TRINITY REHAB
RIDGELAND MS
39158
US

V. Phone/Fax

Practice location:
  • Phone: 601-206-9195
  • Fax: 601-957-8391
Mailing address:
  • Phone: 601-206-9195
  • Fax: 601-957-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA1049
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: