Healthcare Provider Details

I. General information

NPI: 1093478034
Provider Name (Legal Business Name): KIMBERLY ELIZABETH KOSCH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3119 W FAIDLEY AVE
GRAND ISLAND NE
68803-4199
US

IV. Provider business mailing address

1509 W LOUISE ST
GRAND ISLAND NE
68801-6326
US

V. Phone/Fax

Practice location:
  • Phone: 308-384-2333
  • Fax:
Mailing address:
  • Phone: 308-391-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1088
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: