Healthcare Provider Details

I. General information

NPI: 1235341074
Provider Name (Legal Business Name): MARY ANN HALBACH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 HOOVER ST
NEW HOLSTEIN WI
53061-1636
US

IV. Provider business mailing address

1610 HOOVER ST
NEW HOLSTEIN WI
53061-1636
US

V. Phone/Fax

Practice location:
  • Phone: 920-898-5627
  • Fax: 920-898-1375
Mailing address:
  • Phone: 920-898-5627
  • Fax: 920-898-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number937-027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: