Healthcare Provider Details

I. General information

NPI: 1710060777
Provider Name (Legal Business Name): CARISA JANE GULLEDGE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 W MAIN ST
DECATURVILLE TN
38329-8101
US

IV. Provider business mailing address

2877 MCKENZIE RD
PARSONS TN
38363-3413
US

V. Phone/Fax

Practice location:
  • Phone: 731-852-3591
  • Fax: 731-852-2283
Mailing address:
  • Phone: 731-847-6731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1257
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: