MEDICARE: MRS. CRYSTAL YVONNE CONNER COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	5057	NC

General Provider Information

NPI Number	:	1144662669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL YVONNE CONNER COTA/L

Provider Business Mailing Address
First Line	:	624 US HIGHWAY 17 S
Second Line	:	SUITE 5
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-8660
Country	:	US
Telephone Number	:	910-329-4445
Fax Number	:	910-329-4444

Provider Business Practice Location Address
First Line	:	624 US HIGHWAY 17 S
Second Line	:	SUITE 5
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-8660
Country	:	US
Telephone Number	:	910-329-4445
Fax Number	:	910-329-4444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2013
Last Update Date	:	07/29/2013

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