Healthcare Provider Details

I. General information

NPI: 1104057868
Provider Name (Legal Business Name): DOROTHY KIMBERLY GRIZZELL COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM GRIZZELL COTA/L

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 LAFAYETTE AVE.
CINCINNATI OH
45220
US

IV. Provider business mailing address

101 E.STATE ST.
KENNETT SQ. PA
19348
US

V. Phone/Fax

Practice location:
  • Phone: 513-221-1562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number03944
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: