Healthcare Provider Details

I. General information

NPI: 1104305135
Provider Name (Legal Business Name): YESENIA GONZALEZ COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 TOURNAMENT TRAIL DR
LAREDO TX
78041-6564
US

IV. Provider business mailing address

7614 LAGUNA DEL MAR CT APT 427
LAREDO TX
78041-3476
US

V. Phone/Fax

Practice location:
  • Phone: 956-727-3422
  • Fax:
Mailing address:
  • Phone: 956-635-1483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number212573
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: