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General NPI Number Information
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NPI Number | 1396455754
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Entity Type | Individual
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Provider Name | HOLLY GEORGIANA MOORE COTA/L
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Gender | Female
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Dates
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Enumeration Date | 11/28/2022
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Last Update Date | 11/28/2022
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Provider Practice Location Address
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Address Line | 1401 TIFT AVE N STE B
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City | TIFTON
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State | GA
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Zip | 31794-3577
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Country | US
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Telephone | 229-396-5644
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Fax | 855-565-1769
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Provider Business Mailing Address
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Address Line | 69 ATWATER RD
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City | TIFTON
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State | GA
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Zip | 31794-8513
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Country | US
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Telephone | 229-392-6922
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Fax | 855-565-1769
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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 | OTA002554
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License Number State | GA
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