MEDICARE: MRS. AMANDA KAY BLACK 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	A4719	KY

General Provider Information

NPI Number	:	1548506009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA KAY BLACK COTA/L

Provider Business Mailing Address
First Line	:	110 N ARBOR PARK
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40214-2711
Country	:	US
Telephone Number	:	502-724-8108
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 N ARBOR PARK
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40214-2711
Country	:	US
Telephone Number	:	502-724-8108
Fax Number	:

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

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	01/02/2013

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