Healthcare Provider Details

I. General information

NPI: 1871858977
Provider Name (Legal Business Name): ANGELA ROSE KJELLBERG COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 DAVIS ST
HAMMOND WI
54015-9615
US

IV. Provider business mailing address

3775 20TH ST
ELK MOUND WI
54739-4200
US

V. Phone/Fax

Practice location:
  • Phone: 715-796-2218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1269-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: