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General NPI Number Information
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NPI Number | 1275428708
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Entity Type | Individual
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Provider Name | COURTNEY GRIMES COTA/L
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Gender | Male
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Dates
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Enumeration Date | 06/12/2025
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 5960 GETWELL RD
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City | SOUTHAVEN
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State | MS
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Zip | 38672-7318
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Country | US
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Telephone | 662-228-0130
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Fax |
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Provider Business Mailing Address
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Address Line | 3615 HIGHWAY 4 W
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City | HOLLY SPRINGS
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State | MS
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Zip | 38635-7205
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Country | US
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Telephone | 901-552-0484
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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 | 4044
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License Number State | MS
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