Healthcare Provider Details

I. General information

NPI: 1235040890
Provider Name (Legal Business Name): BROOKLYN PETERSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 GLENWOOD AVE
NEW BOSTON OH
45662-5505
US

IV. Provider business mailing address

522 GLENWOOD AVE
NEW BOSTON OH
45662-5505
US

V. Phone/Fax

Practice location:
  • Phone: 740-354-7761
  • Fax:
Mailing address:
  • Phone: 740-961-0402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA008966
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: