Healthcare Provider Details

I. General information

NPI: 1720900343
Provider Name (Legal Business Name): TAMRA WALLACE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 IKE DR
BARNHART MO
63012-1334
US

IV. Provider business mailing address

6665 IKE DR
BARNHART MO
63012-1334
US

V. Phone/Fax

Practice location:
  • Phone: 314-221-8052
  • Fax:
Mailing address:
  • Phone: 314-221-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1999141849
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: