Healthcare Provider Details

I. General information

NPI: 1447596671
Provider Name (Legal Business Name): DIANE LAVERNE GILBERT COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2012
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 S KEATING AVE
CHICAGO IL
60629-5660
US

IV. Provider business mailing address

612 RIDGEFIELD RD
NEW LENOX IL
60451-3340
US

V. Phone/Fax

Practice location:
  • Phone: 773-284-5637
  • Fax:
Mailing address:
  • Phone: 708-548-7405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number057.001903
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057001903
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: