=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730696659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORETTA H REILLY COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2017
-----------------------------------------------------
Last Update Date | 12/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 POWHATAN ST
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22043-1940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-538-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5802 TORINGTON DR UNIT M
-----------------------------------------------------
City | W SPRINGFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22152-1084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-306-9208
-----------------------------------------------------
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 | 0131001930
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------