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NPI Code Detail

MEDICARE: VICTORIA LYNN FAIRLEY-GREEN COTAL

MEDICARE: VICTORIA LYNN FAIRLEY-GREEN COTAL
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
1224Z00000XOccupational Therapy Assistant5202007270MI

General Provider Information

NPI Number : 1568998003
Entity Type Code : Individual
Provider Name (Legal Business Name) : VICTORIA LYNN FAIRLEY-GREEN COTAL
Provider Business Mailing Address
First Line : 29221 MARK AVE
Second Line :
City : MADISON HEIGHTS
State : MI
Zip : 48071-4469
Country : US
Telephone Number : 248-677-4174
Fax Number : 248-677-4174
Provider Business Practice Location Address
First Line : 17177 N LAUREL PARK DR STE 417
Second Line :
City : LIVONIA
State : MI
Zip : 48152-3952
Country : US
Telephone Number : 734-666-5995
Fax Number : 877-414-9925
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2017
Last Update Date : 05/03/2017

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Directions to “ VICTORIA LYNN FAIRLEY-GREEN COTAL” Practice Location

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