MEDICARE: MRS. LESLI ANN SEYFERT COTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	057002480	IL

General Provider Information

NPI Number	:	1639309354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LESLI ANN SEYFERT COTA

Provider Business Mailing Address
First Line	:	1207 MUIRFIELD PT
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-8567
Country	:	US
Telephone Number	:	217-721-3120
Fax Number	:	217-379-2472

Provider Business Practice Location Address
First Line	:	450 E FULTON ST
Second Line	:
City	:	PAXTON
State	:	IL
Zip	:	60957-1716
Country	:	US
Telephone Number	:	217-379-2408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	07/15/2009

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