=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912661570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TALISIA GUYTON COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2021
-----------------------------------------------------
Last Update Date | 10/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 WHITLOCK AVE NW
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30064-2362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-872-0767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 BARRETT LAKES BLVD NW APT 1024
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30144-7532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-739-9945
-----------------------------------------------------
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 | OTA002345
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------