Healthcare Provider Details

I. General information

NPI: 1003748534
Provider Name (Legal Business Name): KRISTIN ROMERO COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 LEWIS AVE
WOOD RIVER IL
62095-2323
US

IV. Provider business mailing address

849 LEWIS AVE
WOOD RIVER IL
62095-2323
US

V. Phone/Fax

Practice location:
  • Phone: 618-610-9419
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.002922
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: