Healthcare Provider Details

I. General information

NPI: 1467721597
Provider Name (Legal Business Name): LISA ANN GROSS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N7135 ROCKY KNOLL PKWY
PLYMOUTH WI
53073-3103
US

IV. Provider business mailing address

W6570 HWY MM
ELKHART LAKE WI
53020-1508
US

V. Phone/Fax

Practice location:
  • Phone: 920-893-6441
  • Fax:
Mailing address:
  • Phone: 920-980-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1218.67
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: