=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255265344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELBY HERNDON GRAVES COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2026
-----------------------------------------------------
Last Update Date | 06/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 668 OLD SALT RD
-----------------------------------------------------
City | SUMRALL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39482-4232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-270-6968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 679 PURVIS OLOH RD
-----------------------------------------------------
City | PURVIS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39475-4285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-310-0336
-----------------------------------------------------
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 | OTA-3800
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------