Healthcare Provider Details

I. General information

NPI: 1023418142
Provider Name (Legal Business Name): SAMANTHA L HENDERSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3057 CLEVELAND AVE SW
CANTON OH
44707-3625
US

IV. Provider business mailing address

408 COMMONWEALTH AVE NE
MASSILLON OH
44646-4526
US

V. Phone/Fax

Practice location:
  • Phone: 330-484-2547
  • Fax:
Mailing address:
  • Phone: 330-760-3576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.05487
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: