Healthcare Provider Details

I. General information

NPI: 1982940052
Provider Name (Legal Business Name): KELLY RAE HALE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W HOUSTON ST
BROKEN ARROW OK
74012-4519
US

IV. Provider business mailing address

4300 W HOUSTON ST
BROKEN ARROW OK
74012-4519
US

V. Phone/Fax

Practice location:
  • Phone: 919-307-0233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0977
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: