Healthcare Provider Details

I. General information

NPI: 1598373227
Provider Name (Legal Business Name): AUTUMN BUSSELLE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 VILLAGE RD
PORT LAVACA TX
77979-2380
US

IV. Provider business mailing address

720 SIDNEY LN
WILLARD MO
65781-7272
US

V. Phone/Fax

Practice location:
  • Phone: 361-552-3741
  • Fax:
Mailing address:
  • Phone: 417-270-6695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number216023
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: