Healthcare Provider Details

I. General information

NPI: 1770828634
Provider Name (Legal Business Name): SAMANTHA RAE BOHN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA RAE BOHN

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 CASSIE CT UNIT 4
EAU CLAIRE WI
54701-3218
US

IV. Provider business mailing address

2442 CASSIE CT UNIT 4
EAU CLAIRE WI
54701-3218
US

V. Phone/Fax

Practice location:
  • Phone: 715-225-9611
  • Fax:
Mailing address:
  • Phone: 715-225-9611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4787-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: