Healthcare Provider Details

I. General information

NPI: 1053947770
Provider Name (Legal Business Name): RACHEL NICOLE HAAK COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N CLYBOURN AVE UNIT C105
CHICAGO IL
60610-2295
US

IV. Provider business mailing address

18427 MILLER DR
LANSING IL
60438-3310
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 708-264-0262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number057005346
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: