Healthcare Provider Details

I. General information

NPI: 1932664422
Provider Name (Legal Business Name): MORGAN BLAIR DZUBA COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS MORGAN TEASTER

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SPRING ST APT I1
BLOUNTVILLE TN
37617-5451
US

IV. Provider business mailing address

210 SPRING ST APT I1
BLOUNTVILLE TN
37617-5451
US

V. Phone/Fax

Practice location:
  • Phone: 276-494-5154
  • Fax:
Mailing address:
  • Phone: 276-494-5154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131001924
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: