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General NPI Number Information
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NPI Number | 1215418900
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Entity Type | Individual
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Provider Name | MODESTY KING COTA
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Gender | Female
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Dates
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Enumeration Date | 08/22/2018
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Last Update Date | 08/22/2018
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Provider Practice Location Address
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Address Line | 716 MIMOSA DR
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City | MINEOLA
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State | TX
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Zip | 75773-2612
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Country | US
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Telephone | 903-569-5366
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Fax |
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Provider Business Mailing Address
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Address Line | 1909 SHILOH RD APT 52
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City | TYLER
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State | TX
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Zip | 75703-2630
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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 | 213950
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License Number State | TX
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