Healthcare Provider Details

I. General information

NPI: 1164855854
Provider Name (Legal Business Name): JULIE M KEITH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E 2ND ST
RICHLAND CENTER WI
53581-1914
US

IV. Provider business mailing address

S9619 RAHL RD
PRAIRIE DU SAC WI
53578-9782
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-6321
  • Fax:
Mailing address:
  • Phone: 608-643-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number196-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: