MEDICARE: ERIN Q KING 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	C1547	WV

General Provider Information

NPI Number	:	1417073982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN Q KING COTA

Provider Business Mailing Address
First Line	:	118 KELLEY AVE
Second Line	:
City	:	WESTERNPORT
State	:	MD
Zip	:	21562-1800
Country	:	US
Telephone Number	:	301-359-0494
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 DIANE DRIVE
Second Line	:
City	:	FORT ASHBY
State	:	WV
Zip	:	26719-1800
Country	:	US
Telephone Number	:	304-298-3602
Fax Number	:

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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