Healthcare Provider Details

I. General information

NPI: 1164191821
Provider Name (Legal Business Name): SAMANTHA DOUGHERTY COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 GRUBB RD
PALMYRA PA
17078-3514
US

IV. Provider business mailing address

107 BROOK LN
MARYSVILLE PA
17053-9500
US

V. Phone/Fax

Practice location:
  • Phone: 717-838-5406
  • Fax:
Mailing address:
  • Phone: 334-414-2189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP009960
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: