Provider Demographics
NPI:1437631603
Name:KULOBA, RUTH (COTA)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:KULOBA
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 1:9821 CHAPEL RD APT 1722
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8299
Mailing Address - Country:US
Mailing Address - Phone:413-204-8112
Mailing Address - Fax:
Practice Address - Street 1:503 MEADOW DR
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-1018
Practice Address - Country:US
Practice Address - Phone:125-472-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215100224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant