=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427525427
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE E ORTEGO COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2018
-----------------------------------------------------
Last Update Date | 10/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4121 OAK HOLLOW LN
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28075-6648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-579-1047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4121 OAK HOLLOW LN
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28075-6648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-579-1047
-----------------------------------------------------
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 | 5193
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------