Healthcare Provider Details

I. General information

NPI: 1902173727
Provider Name (Legal Business Name): DIANE ELIZABETH CUILLO COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 CARMAN RD
DIX HILLS NY
11746-5651
US

IV. Provider business mailing address

140 CAMBON AVE
SAINT JAMES NY
11780-3042
US

V. Phone/Fax

Practice location:
  • Phone: 631-549-5580
  • Fax:
Mailing address:
  • Phone: 631-724-6398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number000496-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: