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General NPI Number Information
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NPI Number | 1992113609
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Entity Type | Individual
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Provider Name | CARLY PORTER COTA/L
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Gender | Female
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Dates
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Enumeration Date | 07/25/2014
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Last Update Date | 06/28/2024
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Provider Practice Location Address
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Address Line | 1501 W COURT ST
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City | PARAGOULD
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State | AR
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Zip | 72450-4025
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Country | US
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Telephone | 870-240-6247
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Fax |
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Provider Business Mailing Address
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Address Line | 783 GREENE 632 RD
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City | PARAGOULD
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State | AR
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Zip | 72450-8525
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Country | US
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Telephone | 870-240-6247
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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 | OT-A878
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License Number State | AR
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