=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497095319
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLA RAE WOLFE COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2013
-----------------------------------------------------
Last Update Date | 03/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7517 W COLDSPRING RD
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53220-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-327-6603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 602 N 4TH ST
-----------------------------------------------------
City | COLBY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54421-9618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-650-2008
-----------------------------------------------------
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 | 4888-27
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------