Healthcare Provider Details

I. General information

NPI: 1104171305
Provider Name (Legal Business Name): MELISSA ROSE SHEA COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N3015 HICKORY RD
BYRON WI
53006-1126
US

IV. Provider business mailing address

414 BROOKRIDGE ST
ALLOUEZ WI
54301-2132
US

V. Phone/Fax

Practice location:
  • Phone: 920-933-4344
  • Fax: 920-482-1273
Mailing address:
  • Phone: 920-471-6198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4824-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: