Healthcare Provider Details

I. General information

NPI: 1477688950
Provider Name (Legal Business Name): THERESA M EVANS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 LOFTON RD
RAPHINE VA
24472-2821
US

IV. Provider business mailing address

431 LOFTON RD
RAPHINE VA
24472-2821
US

V. Phone/Fax

Practice location:
  • Phone: 540-457-1219
  • Fax:
Mailing address:
  • Phone: 540-457-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000210
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: