Healthcare Provider Details

I. General information

NPI: 1598001943
Provider Name (Legal Business Name): SUSAN JUNE MUNOZ COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 SHERIDAN RD
KENOSHA WI
53143-6327
US

IV. Provider business mailing address

410 E BOLIVAR AVENUE
MILW WI
53207
US

V. Phone/Fax

Practice location:
  • Phone: 262-658-4141
  • Fax:
Mailing address:
  • Phone: 414-416-9361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: