=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255935102
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA MCDONALD COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2020
-----------------------------------------------------
Last Update Date | 12/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 PARTRIDGE RUN
-----------------------------------------------------
City | SHEPHERDSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40165-9586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-504-4302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 PARTRIDGE RUN
-----------------------------------------------------
City | SHEPHERDSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40165-9586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-504-4302
-----------------------------------------------------
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 | 134834
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------