Healthcare Provider Details

I. General information

NPI: 1306599402
Provider Name (Legal Business Name): MIRANDA LEE HURST COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRANDA LEE HURST MIRANDA MCNELLEY

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2885 TECHNOLOGY DR
LAKE ST LOUIS MO
63367-4123
US

IV. Provider business mailing address

2600 COMPASS RD
GLENVIEW IL
60026-8001
US

V. Phone/Fax

Practice location:
  • Phone: 636-614-3310
  • Fax:
Mailing address:
  • Phone: 877-787-3430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2022001777
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: