Healthcare Provider Details

I. General information

NPI: 1902002074
Provider Name (Legal Business Name): KIMBERLY DAWN WEBB COTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S 34TH ST
MOUNT VERNON IL
62864-6232
US

IV. Provider business mailing address

23736 KEARNEY RD
EWING IL
62836-1158
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-5700
  • Fax:
Mailing address:
  • Phone: 618-728-4417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: