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General NPI Number Information
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NPI Number | 1811621683
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Entity Type | Individual
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Provider Name | JAIME A LARSEN COTA
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Gender | Female
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Dates
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Enumeration Date | 07/15/2022
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Last Update Date | 07/15/2022
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Provider Practice Location Address
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Address Line | 6407 SOUTHWEST BLVD
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City | BENBROOK
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State | TX
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Zip | 76132-2777
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Country | US
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Telephone | 817-423-5611
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Fax |
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Provider Business Mailing Address
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Address Line | 648 JACIE CT
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City | BURLESON
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State | TX
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Zip | 76028-1324
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Country | US
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Telephone | 817-682-3565
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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 | 216154
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License Number State | TX
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