Healthcare Provider Details

I. General information

NPI: 1295954683
Provider Name (Legal Business Name): MARY BETH WYLIE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 PARK AVE
ADAMSVILLE TN
38310-2461
US

IV. Provider business mailing address

1405 DOWNING HOLLOW RD
WAYNESBORO TN
38485-3846
US

V. Phone/Fax

Practice location:
  • Phone: 731-632-3301
  • Fax:
Mailing address:
  • Phone: 931-722-2832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1254
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: