1194141382 NPI number — KENNETH WILLIAMS COTA/L

Table of content: KENNETH WILLIAMS COTA/L (NPI 1194141382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194141382 NPI number — KENNETH WILLIAMS COTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
KENNETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTA/L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194141382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 N 29TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49037-7847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 N HURSTBOURNE PKWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40222-5185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-412-5847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  L2531727 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)