Healthcare Provider Details

I. General information

NPI: 1518677871
Provider Name (Legal Business Name): LISA JOYCE MILLER COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16044 COUNTY ROAD 165
TYLER TX
75703-7302
US

IV. Provider business mailing address

207 BOIS D ARC DR
BULLARD TX
75757-5015
US

V. Phone/Fax

Practice location:
  • Phone: 903-526-5599
  • Fax:
Mailing address:
  • Phone: 972-768-3892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number209060
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: