Healthcare Provider Details

I. General information

NPI: 1629982467
Provider Name (Legal Business Name): DUSTIN M HERBERT COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 BIRGE DR
CHAUNCEY OH
45719-1100
US

IV. Provider business mailing address

69 WEST ST
JACKSON OH
45640-1566
US

V. Phone/Fax

Practice location:
  • Phone: 740-797-0064
  • Fax: 440-578-7330
Mailing address:
  • Phone: 740-418-4441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA06661
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: