=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558842690
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY E CAMBRON COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2018
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 S WALLACE WILKINSON BLVD
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42539-3344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-787-6889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3657 LINCOLN PARK RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40069-9582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-481-4135
-----------------------------------------------------
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 |
-----------------------------------------------------