=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265803969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA BROWN COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2015
-----------------------------------------------------
Last Update Date | 10/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 CIRCLE DR
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361-1893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-630-8140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140076 VERCRUYSSE RD
-----------------------------------------------------
City | MITCHELL
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69357-3766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-641-2472
-----------------------------------------------------
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 | 918
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------