Healthcare Provider Details

I. General information

NPI: 1518195312
Provider Name (Legal Business Name): TRACEY A BAKER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 S 67TH ST
PHILADELPHIA PA
19142-1625
US

IV. Provider business mailing address

2022 S 67TH ST
PHILADELPHIA PA
19142-1625
US

V. Phone/Fax

Practice location:
  • Phone: 215-729-4016
  • Fax:
Mailing address:
  • Phone: 215-729-4016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP002889L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: