MEDICARE: BRANDI BROADDUS COTA/L

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	057005546	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	057005546	OTHER	IL	COTA

General Provider Information

NPI Number	:	1922763515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI BROADDUS COTA/L

Provider Business Mailing Address
First Line	:	3 MOLLY DR
Second Line	:
City	:	GIRARD
State	:	IL
Zip	:	62640-9580
Country	:	US
Telephone Number	:	217-652-4021
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 GREENHEAD DR STE D
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-7426
Country	:	US
Telephone Number	:	217-891-1524
Fax Number	:

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

Provider Enumeration Date	:	11/08/2021
Last Update Date	:	11/08/2021

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