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General NPI Number Information
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NPI Number | 1043668247
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Entity Type | Individual
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Provider Name | TERESA DEYOUNG COTA
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Gender | Female
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Dates
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Enumeration Date | 05/27/2016
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Last Update Date | 10/10/2019
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Provider Practice Location Address
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Address Line | 5401 PORTAGE RD
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City | PORTAGE
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State | MI
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Zip | 49002-1797
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Country | US
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Telephone | 269-372-7725
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Fax |
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Provider Business Mailing Address
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Address Line | 1490 E BELTLINE AVE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-4336
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Country | US
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Telephone | 616-940-0040
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 5202008106
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License Number State | MI
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