Healthcare Provider Details

I. General information

NPI: 1962894725
Provider Name (Legal Business Name): DONNEISHA SMITH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W 15TH ST
MONAHANS TX
79756-8301
US

IV. Provider business mailing address

3773 N 58TH BLVD
MILWAUKEE WI
53216-2850
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-5092
  • Fax:
Mailing address:
  • Phone: 414-839-4028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number212887
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: