=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801427596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON BRACY COTA/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2020
-----------------------------------------------------
Last Update Date | 01/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 E LA CANADA BLVD
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-932-2282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19443 W MORNING GLORY DR
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-5810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-573-9566
-----------------------------------------------------
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 | 5089
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------