MEDICARE: MRS. GRACE CAROLINA SUNG COTA/L

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	010405-01	NY

General Provider Information

NPI Number	:	1962041822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACE CAROLINA SUNG COTA/L

Provider Business Mailing Address
First Line	:	26B PROSPECT ST
Second Line	:
City	:	PALISADES PARK
State	:	NJ
Zip	:	07650-1129
Country	:	US
Telephone Number	:	201-543-7553
Fax Number	:

Provider Business Practice Location Address
First Line	:	26B PROSPECT ST
Second Line	:
City	:	PALISADES PARK
State	:	NJ
Zip	:	07650-1129
Country	:	US
Telephone Number	:	201-543-7553
Fax Number	:

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

Provider Enumeration Date	:	12/24/2019
Last Update Date	:	12/24/2019

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