Healthcare Provider Details

I. General information

NPI: 1770980716
Provider Name (Legal Business Name): EVELYN DANIELLE STEELE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CLUB VILLAGE DR STE 103
COLUMBIA MO
65203-4411
US

IV. Provider business mailing address

16501 HIGHWAY B
COLE CAMP MO
65325-2342
US

V. Phone/Fax

Practice location:
  • Phone: 573-256-2777
  • Fax:
Mailing address:
  • Phone: 660-596-8597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2014003652
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: