Healthcare Provider Details

I. General information

NPI: 1730190703
Provider Name (Legal Business Name): BARBARA KELLOGG COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 CENTER CT UNIT D
SHOREWOOD IL
60431-8520
US

IV. Provider business mailing address

15249 LAWNDALE AVE
MIDLOTHIAN IL
60445-3763
US

V. Phone/Fax

Practice location:
  • Phone: 815-730-1818
  • Fax:
Mailing address:
  • Phone: 708-389-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number57001435
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: