=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437364379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON KEAN COTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 08/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 606 OLD ROUTE 17
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12701-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-665-6795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 138 CHAMPLIN AVE
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12754-1617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-665-6795
-----------------------------------------------------
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 | OP006416
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 007094
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------