Healthcare Provider Details

I. General information

NPI: 1083298806
Provider Name (Legal Business Name): STACEY BRYANT COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 OAK HILL DR
EDWARDSVILLE IL
62025-2024
US

IV. Provider business mailing address

530 OAK HILL DR
EDWARDSVILLE IL
62025-2024
US

V. Phone/Fax

Practice location:
  • Phone: 618-670-3552
  • Fax:
Mailing address:
  • Phone: 618-670-3552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License Number057-002567
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: