Healthcare Provider Details

I. General information

NPI: 1831468503
Provider Name (Legal Business Name): AMY MICHELLE ST.JOHN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2011
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 SOUTH 102ND ST STE 340 MJ CARE INC
MILWAUKEE WI
53227
US

IV. Provider business mailing address

135 KARL AVE
BELLEVILLE WI
53508-9700
US

V. Phone/Fax

Practice location:
  • Phone: 414-329-2500
  • Fax:
Mailing address:
  • Phone: 608-445-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4751-27
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057003295
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: