Healthcare Provider Details

I. General information

NPI: 1184264392
Provider Name (Legal Business Name): NATALIE LEA GREEN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NATALIE LEA GREEN

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N AVON ST
ROCKFORD IL
61101-5829
US

IV. Provider business mailing address

511 N AVON ST
ROCKFORD IL
61101-5829
US

V. Phone/Fax

Practice location:
  • Phone: 563-210-7471
  • Fax:
Mailing address:
  • Phone: 563-210-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057004594
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: