=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427320274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY DENICE PEACOCK COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2012
-----------------------------------------------------
Last Update Date | 02/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 251 HIGHWAY 66
-----------------------------------------------------
City | NEW HARMONY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47631-9075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-682-4104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 S GARDENGATE DR
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-5527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-748-2049
-----------------------------------------------------
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 | 32001225A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------