MEDICARE: LYNNETTE SALAS COTA

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	212594	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164901450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNNETTE SALAS COTA

Provider Business Mailing Address
First Line	:	515 W LINGLEVILLE RD
Second Line	:
City	:	STEPHENVILLE
State	:	TX
Zip	:	76401-2211
Country	:	US
Telephone Number	:	254-965-3611
Fax Number	:	254-965-3618

Provider Business Practice Location Address
First Line	:	925 SANTA FE DR STE 110
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5867
Country	:	US
Telephone Number	:	817-599-7714
Fax Number	:	254-965-3618

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

Provider Enumeration Date	:	08/08/2018
Last Update Date	:	08/08/2018

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