MEDICARE: COLLEEN A GAVNER 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	2058	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2058	OTHER	CT	STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH

General Provider Information

NPI Number	:	1578187050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN A GAVNER COTA

Provider Business Mailing Address
First Line	:	45 OLD KINGS RD
Second Line	:
City	:	AVON
State	:	CT
Zip	:	06001-2300
Country	:	US
Telephone Number	:	716-310-1565
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 CENTERPOINT DR
Second Line	:
City	:	MIDDLETOWN
State	:	CT
Zip	:	06457-7570
Country	:	US
Telephone Number	:	860-421-4052
Fax Number	:	860-421-4053

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

Provider Enumeration Date	:	06/01/2020
Last Update Date	:	06/01/2020

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