Healthcare Provider Details

I. General information

NPI: 1821241415
Provider Name (Legal Business Name): AUONTWANNQUE B. R. MCCOY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUONTWANNQUE JACKSON COTA/L

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3881-A LEAPHART RD.
WEST COLUMBIA SC
29169
US

IV. Provider business mailing address

3681 LEAPHART RD STE A
WEST COLUMBIA SC
29169-3068
US

V. Phone/Fax

Practice location:
  • Phone: 803-454-6090
  • Fax: 803-451-6105
Mailing address:
  • Phone: 803-454-6090
  • Fax: 803-451-6105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2490
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: