Healthcare Provider Details

I. General information

NPI: 1255729653
Provider Name (Legal Business Name): STEPHANIE SENA COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 MENAUL BLVD NW
ALBUQUERQUE NM
87107-1245
US

IV. Provider business mailing address

1881 CAMINO RINCON SW
LOS LUNAS NM
87031-8808
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-8797
  • Fax:
Mailing address:
  • Phone: 505-414-8797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3170
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: