Healthcare Provider Details

I. General information

NPI: 1326242140
Provider Name (Legal Business Name): JODY MALDONADO COTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 HIGH GROVE BLVD
BURR RIDGE IL
60527-7585
US

IV. Provider business mailing address

604 SARA LN
NAPERVILLE IL
60565-1615
US

V. Phone/Fax

Practice location:
  • Phone: 630-734-4588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: