Healthcare Provider Details

I. General information

NPI: 1972061901
Provider Name (Legal Business Name): CAROL JEAN ZILZ COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 EVERGREEN CT
DECATUR IL
62521-8774
US

IV. Provider business mailing address

10113 JORDAN RD
ARGENTA IL
62501-8115
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-4300
  • Fax:
Mailing address:
  • Phone: 217-454-4605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.000390
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: