Healthcare Provider Details

I. General information

NPI: 1902392186
Provider Name (Legal Business Name): MARIE LE CUYER COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 GUSDORF RD
TAOS NM
87571-6294
US

IV. Provider business mailing address

3101 OLD PECOS TRL UNIT 629
SANTA FE NM
87505-9540
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4337
  • Fax:
Mailing address:
  • Phone: 575-770-9362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3944
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: