Healthcare Provider Details

I. General information

NPI: 1487583787
Provider Name (Legal Business Name): GARY WAYNE BROWN COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S HARBORVIEW DR LOT 26
LAKESIDE MARBLEHEAD OH
43440-2444
US

IV. Provider business mailing address

2200 S HARBORVIEW DR LOT 26
LAKESIDE MARBLEHEAD OH
43440-2444
US

V. Phone/Fax

Practice location:
  • Phone: 419-561-0847
  • Fax:
Mailing address:
  • Phone: 419-561-0847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA002636
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: