Healthcare Provider Details

I. General information

NPI: 1043673676
Provider Name (Legal Business Name): LETICIA AMBER HALL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WALNUT ST
TEXARKANA TX
75501-4446
US

IV. Provider business mailing address

6208 TIMBERCREEK DR
TEXARKANA AR
71854-8192
US

V. Phone/Fax

Practice location:
  • Phone: 903-794-2705
  • Fax:
Mailing address:
  • Phone: 903-691-9059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number213698
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: