MEDICARE: LACY MARIE BEACH 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	215055	TX

General Provider Information

NPI Number	:	1881175305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACY MARIE BEACH COTA

Provider Business Mailing Address
First Line	:	8843 STAGHORN ML
Second Line	:
City	:	CONVERSE
State	:	TX
Zip	:	78109-3754
Country	:	US
Telephone Number	:	760-315-5235
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 ENTERPRISE AVE
Second Line	:
City	:	DEVINE
State	:	TX
Zip	:	78016-1807
Country	:	US
Telephone Number	:	830-663-4451
Fax Number	:

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

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	08/23/2018

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Directions to “ LACY MARIE BEACH COTA” Practice Location

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