Healthcare Provider Details

I. General information

NPI: 1780289876
Provider Name (Legal Business Name): EMILY KLUCK COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10136 HWY D
DIXON MO
65459-7181
US

IV. Provider business mailing address

10136 HWY D
DIXON MO
65459-7181
US

V. Phone/Fax

Practice location:
  • Phone: 573-433-5900
  • Fax:
Mailing address:
  • Phone: 573-433-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2018031493
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: