Healthcare Provider Details

I. General information

NPI: 1184821670
Provider Name (Legal Business Name): STEPHANIE ANN YOUNG COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 HIGHWAY 135 SOUTH
OVERTON TX
75684
US

IV. Provider business mailing address

1164 CR 465
CARTHAGE TX
75633
US

V. Phone/Fax

Practice location:
  • Phone: 903-834-6011
  • Fax:
Mailing address:
  • Phone: 903-692-2183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number209205
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: