MEDICARE: MRS. CINDY LOUISE JOUBERT 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	172V00000X	Community Health Worker	004694-1	NY

General Provider Information

NPI Number	:	1942446737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CINDY LOUISE JOUBERT COTA

Provider Business Mailing Address
First Line	:	118 THE PORTAGE
Second Line	:
City	:	TICONDEROGA
State	:	NY
Zip	:	12883-1415
Country	:	US
Telephone Number	:	518-585-6443
Fax Number	:

Provider Business Practice Location Address
First Line	:	2155 STATE ROUTE 22B
Second Line	:
City	:	MORRISONVILLE
State	:	NY
Zip	:	12962-3417
Country	:	US
Telephone Number	:	518-562-3847
Fax Number	:

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

Provider Enumeration Date	:	12/28/2008
Last Update Date	:	12/28/2008

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