Healthcare Provider Details

I. General information

NPI: 1265316525
Provider Name (Legal Business Name): KENYETTA SIMONE BARNEY COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENYETTA SIMONE EADDY

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4712 CHESTER AVE
PHILADELPHIA PA
19143-3513
US

IV. Provider business mailing address

4712 CHESTER AVE
PHILADELPHIA PA
19143-3513
US

V. Phone/Fax

Practice location:
  • Phone: 215-727-4450
  • Fax:
Mailing address:
  • Phone: 718-974-7218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP010697
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: