Provider Demographics
NPI:1013736339
Name:COTTON, TELISA RENA
Entity type:Individual
Prefix:
First Name:TELISA
Middle Name:RENA
Last Name:COTTON
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 1:306 N PARKER ST
Mailing Address - Street 2:
Mailing Address - City:DAWSON SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42408-1320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 N PARKER ST
Practice Address - Street 2:
Practice Address - City:DAWSON SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42408-1320
Practice Address - Country:US
Practice Address - Phone:270-936-2319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist