Healthcare Provider Details

I. General information

NPI: 1891195384
Provider Name (Legal Business Name): COURTNEY MARANDA COLE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 US HIGHWAY 17 S SUITE 5
HOLLY RIDGE NC
28445-8660
US

IV. Provider business mailing address

117 BARRACUDA CT
N TOPSAIL BEACH NC
28460-8070
US

V. Phone/Fax

Practice location:
  • Phone: 910-329-4444
  • Fax: 910-329-4445
Mailing address:
  • Phone: 336-944-2851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number9245
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: