Healthcare Provider Details

I. General information

NPI: 1508702697
Provider Name (Legal Business Name): ANGELA BERENS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16325 HARLEM AVE STE 100
TINLEY PARK IL
60477-1647
US

IV. Provider business mailing address

1540 N GREENVIEW AVE UNIT D
CHICAGO IL
60642-0009
US

V. Phone/Fax

Practice location:
  • Phone: 708-921-7554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.004883
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: