Healthcare Provider Details

I. General information

NPI: 1831383876
Provider Name (Legal Business Name): CATHY DOMINGUEZ GARCIA COTA L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 MISSOURI AVE
LAS CRUCES NM
88011-4813
US

IV. Provider business mailing address

2905 MISSOURI AVE
LAS CRUCES NM
88011-4813
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-0404
  • Fax:
Mailing address:
  • Phone: 575-522-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2296
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3773
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: