Healthcare Provider Details

I. General information

NPI: 1023550662
Provider Name (Legal Business Name): KAITLYN DIEDRICH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 WASHINGTON
AFTON WY
83110
US

IV. Provider business mailing address

PO BOX 570
MOUNTAIN VIEW WY
82939-0570
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-9286
  • Fax: 307-885-9287
Mailing address:
  • Phone: 307-782-6602
  • Fax: 307-782-7328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberCOTA-1177
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: