MEDICARE: SHAY VERONICA VANDERLOO 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	798	NE

General Provider Information

NPI Number	:	1285861831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAY VERONICA VANDERLOO COTA

Provider Business Mailing Address
First Line	:	3212 PARK LANE DR
Second Line	:
City	:	HASTINGS
State	:	NE
Zip	:	68901-3334
Country	:	US
Telephone Number	:	402-705-9908
Fax Number	:

Provider Business Practice Location Address
First Line	:	414 N WILLSON ST
Second Line	:
City	:	BLUE HILL
State	:	NE
Zip	:	68930-3507
Country	:	US
Telephone Number	:	402-705-9908
Fax Number	:

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

Provider Enumeration Date	:	06/22/2009
Last Update Date	:	06/22/2009

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Directions to “ SHAY VERONICA VANDERLOO COTA” Practice Location

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