Healthcare Provider Details

I. General information

NPI: 1104748094
Provider Name (Legal Business Name): AMANDA KAY BRUINS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N10090 ABBEY RD
CRIVITZ WI
54114-8187
US

IV. Provider business mailing address

N10090 ABBEY RD
CRIVITZ WI
54114-8187
US

V. Phone/Fax

Practice location:
  • Phone: 920-319-2975
  • Fax:
Mailing address:
  • Phone: 920-319-2975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: