MEDICARE: MARY MCDONALD 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	225XP0200X	Pediatric Occupational Therapist	PHY T 2675	AK

General Provider Information

NPI Number	:	1790116275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MCDONALD COTA

Provider Business Mailing Address
First Line	:	4255 POLK RD
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-8056
Country	:	US
Telephone Number	:	812-480-1363
Fax Number	:

Provider Business Practice Location Address
First Line	:	12110 BUSINESS BLVD
Second Line	:	SUITE 6 PMB 413
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7725
Country	:	US
Telephone Number	:	907-317-9349
Fax Number	:	866-628-8601

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

Provider Enumeration Date	:	12/09/2013
Last Update Date	:	12/09/2013

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