Healthcare Provider Details

I. General information

NPI: 1942476601
Provider Name (Legal Business Name): CRYSTAL ANN NEAL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL ANN THOMAS COTA

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 ALDERSON ST
SCHOFIELD WI
54476-3614
US

IV. Provider business mailing address

3108 CALEB DR
WESTON WI
54476-6668
US

V. Phone/Fax

Practice location:
  • Phone: 715-359-4257
  • Fax:
Mailing address:
  • Phone: 715-499-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1923027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: