=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356970826
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA REEK COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2020
-----------------------------------------------------
Last Update Date | 04/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3114 E 46TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46205-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-920-7888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1558 METZLER DR
-----------------------------------------------------
City | PLAINFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46168-8955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-543-2427
-----------------------------------------------------
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 | IN
-----------------------------------------------------