Healthcare Provider Details

I. General information

NPI: 1265673610
Provider Name (Legal Business Name): KRISTIE ANN WIDEEN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 03/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12030 LAWNVIEW AVE
CINCINNATI OH
45246-3041
US

IV. Provider business mailing address

12030 LAWNVIEW AVE
CINCINNATI OH
45246
US

V. Phone/Fax

Practice location:
  • Phone: 513-931-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number04091
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: