Healthcare Provider Details

I. General information

NPI: 1265914089
Provider Name (Legal Business Name): ELISE FULLER COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9009 WHITE ROCK TRL
DALLAS TX
75238-3347
US

IV. Provider business mailing address

3501 ROSS AVE APT 1011
DALLAS TX
75204-5450
US

V. Phone/Fax

Practice location:
  • Phone: 214-355-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number214604
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: