Healthcare Provider Details

I. General information

NPI: 1407463003
Provider Name (Legal Business Name): KRISTI MICHELLE GRANT COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 MEDCOM ST
NORTH CHARLESTON SC
29406-9167
US

IV. Provider business mailing address

9100 MEDCOM ST
NORTH CHARLESTON SC
29406-9167
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-2663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.5167
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: