Healthcare Provider Details

I. General information

NPI: 1245909464
Provider Name (Legal Business Name): LAURA MACKENZIE LIVENGOOD COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 W MAIN ST
BROCTON NY
14716-9749
US

IV. Provider business mailing address

185 CLYDE AVE
JAMESTOWN NY
14701-1767
US

V. Phone/Fax

Practice location:
  • Phone: 716-792-2100
  • Fax:
Mailing address:
  • Phone: 716-720-1573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number010795
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: