Healthcare Provider Details

I. General information

NPI: 1629736038
Provider Name (Legal Business Name): BEVERLY CHRISTIAN COLEMAN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 TROTWOOD AVE
COLUMBIA TN
38401-5074
US

IV. Provider business mailing address

2321 FALL RIVER RD
LEOMA TN
38468-5463
US

V. Phone/Fax

Practice location:
  • Phone: 931-398-6300
  • Fax:
Mailing address:
  • Phone: 931-224-6530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3563
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: