Healthcare Provider Details

I. General information

NPI: 1295566255
Provider Name (Legal Business Name): LISA VENTURA COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 GALWAY DR
ALAMOGORDO NM
88310-7845
US

IV. Provider business mailing address

PO BOX 352
CARRIZOZO NM
88301-0352
US

V. Phone/Fax

Practice location:
  • Phone: 575-495-2880
  • Fax:
Mailing address:
  • Phone: 575-937-7789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-2023-0204
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: