Healthcare Provider Details

I. General information

NPI: 1427260876
Provider Name (Legal Business Name): KORIE GRAHAM COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S. COLUMBIA RD.
GRAND FORKS ND
58201
US

IV. Provider business mailing address

4750 33RD AVE. NE
FORDVILLE ND
58231
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6000
  • Fax:
Mailing address:
  • Phone: 719-201-9548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1024205
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: