=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962685024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDI PETERSON COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2007
-----------------------------------------------------
Last Update Date | 12/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2865 E MAIN ST
-----------------------------------------------------
City | HUMBOLDT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38343-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-824-0057
-----------------------------------------------------
Fax | 731-784-1510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2865 E MAIN ST
-----------------------------------------------------
City | HUMBOLDT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38343-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-824-0057
-----------------------------------------------------
Fax | 731-784-1510
-----------------------------------------------------
=====================================================
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 | 0000000957
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------