Healthcare Provider Details

I. General information

NPI: 1700120870
Provider Name (Legal Business Name): LYNN MARIE KOWALSKI COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNN MOLLERUD COTA/L

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S COLUMBIA RD
GRAND FORKS ND
58201-4032
US

IV. Provider business mailing address

1000 S COLUMBIA RD
GRAND FORKS ND
58201-4032
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5000
  • Fax:
Mailing address:
  • Phone: 701-780-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1229
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: