Healthcare Provider Details

I. General information

NPI: 1154533909
Provider Name (Legal Business Name): KIRSTEN CORINNE WILSON COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 E ALFRED ST
WEYAUWEGA WI
54983-9024
US

IV. Provider business mailing address

8789 EDGEWATER RDG
OMRO WI
54963-9800
US

V. Phone/Fax

Practice location:
  • Phone: 920-867-3121
  • Fax:
Mailing address:
  • Phone: 920-685-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number991-027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: