Provider Demographics
NPI:1548667363
Name:KOTT, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:KOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16711 DAVIS HOLLOW RD SE
Mailing Address - Street 2:
Mailing Address - City:OLDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21555-1359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 DIANE DR
Practice Address - Street 2:
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719
Practice Address - Country:US
Practice Address - Phone:304-298-3602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1893224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant