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General NPI Number Information
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NPI Number | 1063914216
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Entity Type | Individual
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Provider Name | JESSICA TOBUREN COTAL
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Gender | Female
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Dates
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Enumeration Date | 03/04/2018
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Last Update Date | 03/04/2018
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Provider Practice Location Address
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Address Line | 15101 FORD RD
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City | DEARBORN
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State | MI
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Zip | 48126-4611
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Country | US
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Telephone | 313-584-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 6718 LINDEN DR
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City | MONROE
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State | MI
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Zip | 48162-9630
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Country | US
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Telephone |
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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 | 202008256
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License Number State | MI
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