Healthcare Provider Details

I. General information

NPI: 1053804880
Provider Name (Legal Business Name): LORINDA GOLAB COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 S AVERS AVE
CHICAGO IL
60632-3627
US

IV. Provider business mailing address

1308 JENNA DR UNIT A
SOUTH ELGIN IL
60177-3425
US

V. Phone/Fax

Practice location:
  • Phone: 773-317-1315
  • Fax:
Mailing address:
  • Phone: 773-317-1315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.005589
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-44844
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: