Healthcare Provider Details

I. General information

NPI: 1386741098
Provider Name (Legal Business Name): CRYSTAL MARIE HARRIE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CAVETTE HILL LN 4550 PHS EAST
KNOXVILLE TN
37934-6673
US

IV. Provider business mailing address

215 BRUSHY VALLEY RD
CLINTON TN
37716-6930
US

V. Phone/Fax

Practice location:
  • Phone: 865-777-4000
  • Fax:
Mailing address:
  • Phone: 865-457-6814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1572
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: