=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366278103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRIE DRAPER COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 09/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21083 N JOHN WAYNE PKWY STE C104
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85139-2961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-233-7555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1157 W MESQUITE ST
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85233-5272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-414-9433
-----------------------------------------------------
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 | OTA-006435
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------