Healthcare Provider Details

I. General information

NPI: 1013320852
Provider Name (Legal Business Name): WINSOME BACKER COTAQ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WINSOME E PAULMAN

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MAPLE ST
SUTHERLAND NE
69165-3000
US

IV. Provider business mailing address

PO BOX 307
SUTHERLAND NE
69165
US

V. Phone/Fax

Practice location:
  • Phone: 908-386-4393
  • Fax:
Mailing address:
  • Phone: 908-386-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number883
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: