Healthcare Provider Details

I. General information

NPI: 1174664122
Provider Name (Legal Business Name): CONNIE SUE BROWN COTA L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 COTTAGE DR
COLLINSVILLE IL
62234-4416
US

IV. Provider business mailing address

109 COTTAGE DR
COLLINSVILLE IL
62234-4416
US

V. Phone/Fax

Practice location:
  • Phone: 618-345-8319
  • Fax:
Mailing address:
  • Phone: 618-345-8319
  • 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: