Healthcare Provider Details

I. General information

NPI: 1053703934
Provider Name (Legal Business Name): OLIVIA BISHOP COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13550 S OUTER 40 RD
CHESTERFIELD MO
63017-5812
US

IV. Provider business mailing address

2807 GREENLEAF DR
SAINT CHARLES MO
63303-5018
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-1330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2013034839
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: