Provider Demographics
NPI:1093064792
Name:EDWARDS, MARY C (COTA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:C
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1168 S MONTCLAIR DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-2650
Mailing Address - Country:US
Mailing Address - Phone:719-406-6734
Mailing Address - Fax:
Practice Address - Street 1:1168 S MONTCLAIR DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-2650
Practice Address - Country:US
Practice Address - Phone:719-406-6734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000414224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant