Healthcare Provider Details

I. General information

NPI: 1114671351
Provider Name (Legal Business Name): KEIRRA LOUISE SEXTON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date: 02/05/2024
Reactivation Date: 02/26/2024

III. Provider practice location address

1000 SAINT LOUIS AVE STE 102
FORT WORTH TX
76104-3377
US

IV. Provider business mailing address

5220 SPRING VALLEY RD STE 300
DALLAS TX
75254-1944
US

V. Phone/Fax

Practice location:
  • Phone: 817-921-5020
  • Fax:
Mailing address:
  • Phone: 469-291-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number218242
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: