Healthcare Provider Details

I. General information

NPI: 1548641285
Provider Name (Legal Business Name): COURTNEY MARIE WINFREY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 2ND AVE SW FL 3
MIAMI OK
74354
US

IV. Provider business mailing address

1115 HARBOR RD
GROVE OK
74344-3505
US

V. Phone/Fax

Practice location:
  • Phone: 918-540-7736
  • Fax: 918-540-7739
Mailing address:
  • Phone: 918-786-4434
  • Fax: 918-786-4435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1373
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: