Healthcare Provider Details

I. General information

NPI: 1831669712
Provider Name (Legal Business Name): ASH-LEIGH MARIE KOWALCZYK COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 SMITH ST
NEW LONDON WI
54961-1410
US

IV. Provider business mailing address

307 SMITH ST
NEW LONDON WI
54961-1410
US

V. Phone/Fax

Practice location:
  • Phone: 920-982-5440
  • Fax: 920-250-5727
Mailing address:
  • Phone: 920-982-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5549-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: