Healthcare Provider Details

I. General information

NPI: 1295269991
Provider Name (Legal Business Name): AUDREY AWA COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 LEE HWY
ARLINGTON VA
22207-3717
US

IV. Provider business mailing address

3508 LEE HWY
ARLINGTON VA
22207-3717
US

V. Phone/Fax

Practice location:
  • Phone: 703-243-4601
  • Fax: 757-773-3402
Mailing address:
  • Phone: 703-243-4601
  • Fax: 202-379-1797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number366937
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: