Healthcare Provider Details

I. General information

NPI: 1730359670
Provider Name (Legal Business Name): JOANN LUCILLE SMITHSON COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 SHANNON ST
EAST PRAIRIE MO
63845-1540
US

IV. Provider business mailing address

126 SHANNON ST
EAST PRAIRIE MO
63845-1540
US

V. Phone/Fax

Practice location:
  • Phone: 573-649-3136
  • Fax:
Mailing address:
  • Phone: 573-649-3136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1999140385
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: