Healthcare Provider Details

I. General information

NPI: 1215693650
Provider Name (Legal Business Name): TAYLOR CASTELLANO COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAYLOR DAVIS

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 N 13TH ST
HERRIN IL
62948-2839
US

IV. Provider business mailing address

205 EXCALIBUR DR
CARTERVILLE IL
62918-3570
US

V. Phone/Fax

Practice location:
  • Phone: 618-942-7391
  • Fax:
Mailing address:
  • Phone: 618-697-3678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057004375
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: