MEDICARE: MRS. TIFFANY BLAIR DECKER 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	213560	TX

General Provider Information

NPI Number	:	1598268120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANY BLAIR DECKER COTA

Provider Business Mailing Address
First Line	:	2400 WESTPORT PKWY STE 1300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-5316
Country	:	US
Telephone Number	:	817-773-6841
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 WESTPORT PKWY STE 1300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-5316
Country	:	US
Telephone Number	:	817-773-6841
Fax Number	:

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

Provider Enumeration Date	:	03/09/2018
Last Update Date	:	03/09/2018

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