Healthcare Provider Details

I. General information

NPI: 1265800387
Provider Name (Legal Business Name): ALEXIS ICE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2015
Last Update Date: 09/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6021 N LIDGERWOOD ST
SPOKANE WA
99208-1125
US

IV. Provider business mailing address

2822 W CROWN AVE
SPOKANE WA
99205-5822
US

V. Phone/Fax

Practice location:
  • Phone: 509-489-3323
  • Fax:
Mailing address:
  • Phone: 509-294-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOC 60583403
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: