Healthcare Provider Details

I. General information

NPI: 1841633435
Provider Name (Legal Business Name): CANDACE C OGNOSKI COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 DIECKMAN RD
CHEHALIS WA
98532-9614
US

IV. Provider business mailing address

179 DIECKMAN RD
CHEHALIS WA
98532-9614
US

V. Phone/Fax

Practice location:
  • Phone: 360-748-3384
  • Fax: 360-748-8360
Mailing address:
  • Phone: 360-748-3384
  • Fax: 360-748-8360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOC 60335983
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: