MEDICARE: MS. WANJA WACIUMA WALCHLI 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	211126	TX

General Provider Information

NPI Number	:	1346720323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WANJA WACIUMA WALCHLI COTA

Provider Business Mailing Address
First Line	:	2519 JOHN WEST RD APT 11102
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75228-8841
Country	:	US
Telephone Number	:	469-877-4282
Fax Number	:

Provider Business Practice Location Address
First Line	:	2815 MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-2320
Country	:	US
Telephone Number	:	214-586-1095
Fax Number	:

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

Provider Enumeration Date	:	08/18/2018
Last Update Date	:	08/18/2018

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