Healthcare Provider Details

I. General information

NPI: 1679019947
Provider Name (Legal Business Name): KATIE M CUNNINGHAM COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 MAPLE LN
ASHLAND WI
54806-3610
US

IV. Provider business mailing address

1635 MAPLE LN
ASHLAND WI
54806-3610
US

V. Phone/Fax

Practice location:
  • Phone: 715-685-5400
  • Fax: 715-685-5102
Mailing address:
  • Phone: 715-685-5400
  • Fax: 715-685-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5293-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: