Healthcare Provider Details

I. General information

NPI: 1154829885
Provider Name (Legal Business Name): KATELYN ANN RUSSELL COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WARRINGTON AVE
DANVILLE IL
61832-5446
US

IV. Provider business mailing address

2251 W STONE BLUFF RD
COVINGTON IN
47932-8103
US

V. Phone/Fax

Practice location:
  • Phone: 217-446-0660
  • Fax: 217-446-9839
Mailing address:
  • Phone: 217-504-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.003857
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: