Healthcare Provider Details

I. General information

NPI: 1629190608
Provider Name (Legal Business Name): LISA MARIE MCDANIEL COTA.L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 KING TREE DR
DAYTON OH
45405-1401
US

IV. Provider business mailing address

2901 ARGELLA AVE
DAYTON OH
45410-3152
US

V. Phone/Fax

Practice location:
  • Phone: 937-278-0723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number03496
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: