Healthcare Provider Details

I. General information

NPI: 1083002869
Provider Name (Legal Business Name): KATIE YACEVICH COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2015
Last Update Date: 01/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 BROOKDALE DR
STATESVILLE NC
28677-4107
US

IV. Provider business mailing address

521 BROOKDALE DR
STATESVILLE NC
28677-4107
US

V. Phone/Fax

Practice location:
  • Phone: 828-775-4660
  • Fax: 980-225-0189
Mailing address:
  • Phone: 828-775-4660
  • Fax: 980-225-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number9293
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: