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General NPI Number Information
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NPI Number | 1568998003
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Entity Type | Individual
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Provider Name | VICTORIA LYNN FAIRLEY-GREEN COTAL
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Gender | Female
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Dates
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Enumeration Date | 05/03/2017
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Last Update Date | 05/03/2017
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Provider Practice Location Address
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Address Line | 17177 N LAUREL PARK DR STE 417
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City | LIVONIA
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State | MI
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Zip | 48152-3952
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Country | US
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Telephone | 734-666-5995
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Fax | 877-414-9925
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Provider Business Mailing Address
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Address Line | 29221 MARK AVE
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City | MADISON HEIGHTS
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State | MI
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Zip | 48071-4469
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Country | US
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Telephone | 248-677-4174
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Fax | 248-677-4174
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 5202007270
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License Number State | MI
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