Healthcare Provider Details

I. General information

NPI: 1033414008
Provider Name (Legal Business Name): DENEICIA L GASAWAY COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 OLD JACKSONVILLE RD
TYLER TX
75701-8510
US

IV. Provider business mailing address

314 LINCOLN STREET
TRINIDAD TX
75163
US

V. Phone/Fax

Practice location:
  • Phone: 903-561-7835
  • Fax:
Mailing address:
  • Phone: 903-275-7817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number210613
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: