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General NPI Number Information
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NPI Number | 1417675919
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Entity Type | Individual
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Provider Name | CAMERON MACKENZIE WALLEY COTA
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Gender | Female
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Dates
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Enumeration Date | 08/19/2022
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Last Update Date | 09/08/2025
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Provider Practice Location Address
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Address Line | 2118 SANDY LN
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City | LAUREL
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State | MS
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Zip | 39443-9087
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Country | US
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Telephone | 601-342-2923
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Fax | 601-255-8623
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Provider Business Mailing Address
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Address Line | 7318 UNION RD
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City | RICHTON
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State | MS
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Zip | 39476-7813
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Country | US
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Telephone |
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Fax |
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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 | OTA-4085
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License Number State | MS
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