Healthcare Provider Details

I. General information

NPI: 1538365317
Provider Name (Legal Business Name): KELLY JO POWELL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 GALLERIA CLUB LN APT 203
CHARLOTTE NC
28270-2529
US

IV. Provider business mailing address

1619 GALLERIA CLUB LN APT 203
CHARLOTTE NC
28270-2529
US

V. Phone/Fax

Practice location:
  • Phone: 704-246-4297
  • Fax:
Mailing address:
  • Phone: 704-246-4297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6247
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2704
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: