MEDICARE: LISA M KRUSSOW 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	32001099A	IN

General Provider Information

NPI Number	:	1669607446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M KRUSSOW COTA

Provider Business Mailing Address
First Line	:	1350 N TODD DR
Second Line	:
City	:	SCOTTSBURG
State	:	IN
Zip	:	47170-7755
Country	:	US
Telephone Number	:	812-414-2660
Fax Number	:	812-414-2661

Provider Business Practice Location Address
First Line	:	1350 N TODD DR
Second Line	:
City	:	SCOTTSBURG
State	:	IN
Zip	:	47170-7755
Country	:	US
Telephone Number	:	812-414-2660
Fax Number	:	812-414-2661

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

Provider Enumeration Date	:	05/21/2009
Last Update Date	:	04/02/2010

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