Healthcare Provider Details

I. General information

NPI: 1811452121
Provider Name (Legal Business Name): ERIN NICOLE RIVENBURG COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030-6904
US

IV. Provider business mailing address

2408 WILDWOOD CIR
AMISSVILLE VA
20106-1897
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax:
Mailing address:
  • Phone: 540-532-3617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: