Healthcare Provider Details

I. General information

NPI: 1700107406
Provider Name (Legal Business Name): MADENA WHITESELL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LOCUST ST
MINONK IL
61760-1511
US

IV. Provider business mailing address

550 FRONTAGE RD SUITE 2415
NORTHFIELD IL
60093-1202
US

V. Phone/Fax

Practice location:
  • Phone: 309-432-2557
  • Fax: 309-432-3330
Mailing address:
  • Phone: 847-441-5593
  • Fax: 847-441-0734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057001032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: