MEDICARE: MS. EDNA ANN COOPER 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	OTA001141	GA

General Provider Information

NPI Number	:	1184996084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EDNA ANN COOPER COTA/L

Provider Business Mailing Address
First Line	:	1889 OLD HWY 29
Second Line	:
City	:	HARTWELL
State	:	GA
Zip	:	30643-8703
Country	:	US
Telephone Number	:	706-680-9064
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 SAGEWOOD DR
Second Line	:	SUITE H423
City	:	PARK CITY
State	:	UT
Zip	:	84098-7502
Country	:	US
Telephone Number	:	888-499-4904
Fax Number	:	435-658-4954

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

Provider Enumeration Date	:	02/08/2012
Last Update Date	:	02/08/2012

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