Healthcare Provider Details

I. General information

NPI: 1942611017
Provider Name (Legal Business Name): SHELLY PENN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 HILL ST
WATERTOWN WI
53098-3016
US

IV. Provider business mailing address

116 DAYTON ST APT B
WATERTOWN WI
53094-3610
US

V. Phone/Fax

Practice location:
  • Phone: 920-206-4935
  • Fax:
Mailing address:
  • Phone: 608-566-0113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5026-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: