Healthcare Provider Details

I. General information

NPI: 1982767356
Provider Name (Legal Business Name): SELENE W DISMUKES COTA L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NHC SCOTT BUFFALO RD
LAWERENCEBURG TN
38464
US

IV. Provider business mailing address

73 LODI RD
WESTPOINT TN
38486
US

V. Phone/Fax

Practice location:
  • Phone: 931-762-9418
  • Fax: 931-766-0573
Mailing address:
  • Phone: 931-766-0287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA951
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: