Healthcare Provider Details

I. General information

NPI: 1306313275
Provider Name (Legal Business Name): STEPHANIE RENEE MERGENTIME COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030
US

IV. Provider business mailing address

3954 BRICKERT PL
WOODBRIDGE VA
22192-7447
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax:
Mailing address:
  • Phone: 256-226-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131002089
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4609
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: