Healthcare Provider Details

I. General information

NPI: 1366843435
Provider Name (Legal Business Name): PAIGE CUPP COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E. FOURTEENTH STREET
KAUKAUNA WI
54130-3308
US

IV. Provider business mailing address

1828 DEXTER ST.
NEW LONDON WI
54961-8237
US

V. Phone/Fax

Practice location:
  • Phone: 920-766-6020
  • Fax:
Mailing address:
  • Phone: 920-250-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number508827
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: