=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508169202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE LEANN HARVEY COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2010
-----------------------------------------------------
Last Update Date | 12/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 SUTPHIN DR
-----------------------------------------------------
City | MARMET
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25315-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-949-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 405
-----------------------------------------------------
City | GLEN FORK
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25845-0405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-237-7003
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------