Healthcare Provider Details

I. General information

NPI: 1558619163
Provider Name (Legal Business Name): MELISSA J LATHROP COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 HILL ST
WATERTOWN WI
53098-3016
US

IV. Provider business mailing address

704 LEXINGTON BLVD.
FORT ATKINSON WI
53538-9322
US

V. Phone/Fax

Practice location:
  • Phone: 920-206-4935
  • Fax:
Mailing address:
  • Phone: 920-650-7728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4923-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: