MEDICARE: SANDRA CECILIA LYLES 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	214989	TX

General Provider Information

NPI Number	:	1558826099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA CECILIA LYLES COTA

Provider Business Mailing Address
First Line	:	9036 MOUNT SHASTA DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79904-1550
Country	:	US
Telephone Number	:	915-276-6155
Fax Number	:

Provider Business Practice Location Address
First Line	:	9036 MOUNT SHASTA DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79904-1550
Country	:	US
Telephone Number	:	915-276-6155
Fax Number	:

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

Provider Enumeration Date	:	02/08/2019
Last Update Date	:	02/08/2019

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