Healthcare Provider Details

I. General information

NPI: 1427392851
Provider Name (Legal Business Name): MICHELLE LEIGH WYRICK COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 HARMON LN
LAKE CITY TN
37769-5338
US

IV. Provider business mailing address

283 HARMON LN
LAKE CITY TN
37769-5338
US

V. Phone/Fax

Practice location:
  • Phone: 865-426-9481
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number000001652
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: