=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285385724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA COOK COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2022
-----------------------------------------------------
Last Update Date | 01/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 S MURPHY AVE
-----------------------------------------------------
City | BRAZIL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47834-8391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-446-2636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1330 N FOREST LN
-----------------------------------------------------
City | BRAZIL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47834-6828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-605-2734
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------