Healthcare Provider Details

I. General information

NPI: 1043369184
Provider Name (Legal Business Name): DAWN FASANO-HICKS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 BLOOMFIELD AVE
WEST CALDWELL NJ
07006-7127
US

IV. Provider business mailing address

150 GASTON AVE
GARFIELD NJ
07026-1208
US

V. Phone/Fax

Practice location:
  • Phone: 973-575-7576
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA09053900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: