Healthcare Provider Details

I. General information

NPI: 1134041148
Provider Name (Legal Business Name): MADILYN GRACE LACK COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 STATE HIGHWAY 142W
GATEWOOD MO
63942-7619
US

IV. Provider business mailing address

109 MUSKRAT LN
DONIPHAN MO
63935-6502
US

V. Phone/Fax

Practice location:
  • Phone: 573-255-3213
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2026029031
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: