Healthcare Provider Details

I. General information

NPI: 1912276148
Provider Name (Legal Business Name): TRACY A. HEFFERON COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 BEDFORD AVE
MIDDLETOWN NY
10940-6414
US

IV. Provider business mailing address

200 WOODHILLS DR APT. 204
GOSHEN NY
10924-1404
US

V. Phone/Fax

Practice location:
  • Phone: 845-326-1776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number001500-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: