Healthcare Provider Details

I. General information

NPI: 1619121894
Provider Name (Legal Business Name): LAURIE COLLISTER COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4390 BELLE OAKS DR SUITE 120
NORTH CHARLESTON SC
29405-8559
US

IV. Provider business mailing address

506 GALESBURG DR
MONROE NC
28110-7331
US

V. Phone/Fax

Practice location:
  • Phone: 843-571-2700
  • Fax:
Mailing address:
  • Phone: 704-776-4932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2409
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4507
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: