Healthcare Provider Details

I. General information

NPI: 1760865802
Provider Name (Legal Business Name): DESTINY WALESIAK COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W 3RD ST
BORGER TX
79007-4008
US

IV. Provider business mailing address

314 CORONADO ST
FRITCH TX
79036-8162
US

V. Phone/Fax

Practice location:
  • Phone: 806-274-9856
  • Fax:
Mailing address:
  • Phone: 806-886-1789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number212171
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: