MEDICARE: KIMBERLY SUE BRADDOCK 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	OTA007843	OH

General Provider Information

NPI Number	:	1194300608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY SUE BRADDOCK COTA

Provider Business Mailing Address
First Line	:	7171 KECK PARK CIR NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-6301
Country	:	US
Telephone Number	:	330-498-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 DEER TRCE
Second Line	:
City	:	NEWARK
State	:	OH
Zip	:	43055-9746
Country	:	US
Telephone Number	:	740-405-6544
Fax Number	:

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

Provider Enumeration Date	:	03/16/2021
Last Update Date	:	03/16/2021

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