Provider Demographics
NPI:1699111468
Name:COTA
Entity type:Organization
Organization Name:COTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:MS
Authorized Official - First Name:KAITLIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-313-2555
Mailing Address - Street 1:2609 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1963
Mailing Address - Country:US
Mailing Address - Phone:219-313-2555
Mailing Address - Fax:
Practice Address - Street 1:2609 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1963
Practice Address - Country:US
Practice Address - Phone:219-313-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine