=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417116948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPHIA LUCINDA BRAGG COTA L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 06/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5790 DENLINGER RD FRIENDSHIP VILLAGE HEALTH CENTER
-----------------------------------------------------
City | TROTWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-837-5581
-----------------------------------------------------
Fax | 937-837-4987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 SPRING FOREST RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27616-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-424-5080
-----------------------------------------------------
Fax | 919-424-5085
-----------------------------------------------------
=====================================================
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 | 03850
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------