MEDICARE: MISS TARA AMBER KIRBY 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	341	OK

General Provider Information

NPI Number	:	1568618205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TARA AMBER KIRBY COTA

Provider Business Mailing Address
First Line	:	512 N CHICKASAW ST
Second Line	:
City	:	PAULS VALLEY
State	:	OK
Zip	:	73075-2408
Country	:	US
Telephone Number	:	405-207-7237
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 NW EXPRESSWAY STE 809
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-5466
Country	:	US
Telephone Number	:	405-917-7160
Fax Number	:

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

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	08/13/2008

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