Healthcare Provider Details

I. General information

NPI: 1235480203
Provider Name (Legal Business Name): BRANDI NICOLE HOBBS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LAFAYETTE AVE E
MATTOON IL
61938-4641
US

IV. Provider business mailing address

410 W PARK ST
THOMASBORO IL
61878-9726
US

V. Phone/Fax

Practice location:
  • Phone: 217-235-5449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057003615
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: