=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669884292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA ANN POWELL COTA/L, PAMPCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2014
-----------------------------------------------------
Last Update Date | 06/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 WILLOW ST
-----------------------------------------------------
City | MONT ALTO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17237-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-217-9938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 WILLOW ST
-----------------------------------------------------
City | MONT ALTO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17237-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-217-9938
-----------------------------------------------------
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 | A01897
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OP007308
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------