MEDICARE: ELIZABETH ANN JACKSON 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	32001765A	IN

General Provider Information

NPI Number	:	1255766002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ANN JACKSON COTA

Provider Business Mailing Address
First Line	:	110 E MAIN STREET
Second Line	:
City	:	LIBERTY MILLS
State	:	IN
Zip	:	46946-0000
Country	:	US
Telephone Number	:	260-578-1380
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 E PRAIRIE ST
Second Line	:
City	:	WARSAW
State	:	IN
Zip	:	46580-4429
Country	:	US
Telephone Number	:	260-578-1380
Fax Number	:

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

Provider Enumeration Date	:	09/12/2013
Last Update Date	:	09/13/2013

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