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General NPI Number Information
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NPI Number | 1669018917
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Entity Type | Individual
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Provider Name | LACY ROSE MILES COTA
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Gender | Female
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Dates
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Enumeration Date | 11/21/2019
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Last Update Date | 11/21/2019
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Provider Practice Location Address
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Address Line | 415 S 1ST ST STE 300A
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City | LUFKIN
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State | TX
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Zip | 75901-3863
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Country | US
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Telephone | 936-225-1174
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Fax |
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Provider Business Mailing Address
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Address Line | 204 PRICE ST
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City | MARSHALL
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State | TX
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Zip | 75670-3523
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Country | US
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Telephone | 903-742-1997
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Fax |
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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 | 216015
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License Number State | TX
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