Healthcare Provider Details

I. General information

NPI: 1174619118
Provider Name (Legal Business Name): BETHANY ANN STEWART COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E MORLEY
MARQUAND MO
63655-9161
US

IV. Provider business mailing address

206 LULA AVE
SCOTT CITY MO
63780-1513
US

V. Phone/Fax

Practice location:
  • Phone: 573-986-1521
  • Fax:
Mailing address:
  • Phone: 573-986-1521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2003014142
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: