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Com Page 12 for EACH PTA COTA ATC LMT declined. PTA COTA Massage Therapist ATC s Professional/Specialty InformationPLEASE FILL OUT FOR ALL PTA COTA ATC and LMT practitioners. Practitioner Name Maiden Name if applicable Other Name if applicable Date of Birth MM/DD/YYYY Professional Degree Issuing Institution Address of Issuing Institution Degree Attendance Dates MM/DD/YYYY to MM/DD/YYYY Post-Graduate Education Internship Residency Specialty Fellowship Teaching Appointment Institution Address...
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