Healthcare Provider Details

I. General information

NPI: 1437479110
Provider Name (Legal Business Name): RUTH MARIE BOHN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 NORTH MACY STREET
FOND DU LAC WI
54935
US

IV. Provider business mailing address

244 NORTH MACY STREET
FOND DU LAC WI
54935
US

V. Phone/Fax

Practice location:
  • Phone: 920-921-9520
  • Fax: 920-924-7859
Mailing address:
  • Phone: 920-921-9520
  • Fax: 920-921-0819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number522-027
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: