Healthcare Provider Details

I. General information

NPI: 1023573169
Provider Name (Legal Business Name): EVINCE EDOUARD COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LINK DR
ROCKLEIGH NJ
07647-2504
US

IV. Provider business mailing address

744 ELM AVE APT 5B
TEANECK NJ
07666-2331
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number46TA09147700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: