=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003565433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN BUSHEE COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2022
-----------------------------------------------------
Last Update Date | 09/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5317 SACANDAGA RD
-----------------------------------------------------
City | GALWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12074-2423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-749-3041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1910 CAMBRIDGE MANOR DR
-----------------------------------------------------
City | SCOTIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12302-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-461-1577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 011049-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------