=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427367234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLYE CRIM COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2010
-----------------------------------------------------
Last Update Date | 09/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1764 TROY RD
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47501-8210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-254-2750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10799 BAXTER CEMETERY RD
-----------------------------------------------------
City | SHOALS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47581-7734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-709-2296
-----------------------------------------------------
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 | 32000988A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------