Healthcare Provider Details

I. General information

NPI: 1790201275
Provider Name (Legal Business Name): MARGO ELENA VANDER WOUDE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 LATTIMORE RD
FERNDALE WA
98248-9424
US

IV. Provider business mailing address

1322 LATTIMORE RD
FERNDALE WA
98248-9424
US

V. Phone/Fax

Practice location:
  • Phone: 615-516-3794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.OC.61347119
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASS.MA.70155732
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: