Healthcare Provider Details

I. General information

NPI: 1942518733
Provider Name (Legal Business Name): TARA BENITA QUARLES COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 RHAWN ST APT 24B
PHILADELPHIA PA
19152-3451
US

IV. Provider business mailing address

2727 RHAWN ST APT 24B
PHILADELPHIA PA
19152-3451
US

V. Phone/Fax

Practice location:
  • Phone: 267-325-4400
  • Fax:
Mailing address:
  • Phone: 267-325-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number46TA09026700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: