MEDICARE: DESTANI AMONI JONES 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	16216	NC

General Provider Information

NPI Number	:	1346066370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTANI AMONI JONES COTA/L

Provider Business Mailing Address
First Line	:	5805 HORSE PASTURE LN APT 232
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-3351
Country	:	US
Telephone Number	:	315-679-3224
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 BACK CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:	704-986-7291
Fax Number	:

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

Provider Enumeration Date	:	11/25/2024
Last Update Date	:	11/25/2024

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