Healthcare Provider Details

I. General information

NPI: 1942512488
Provider Name (Legal Business Name): PHYLLIS FAY CAUDILL-JAMES COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 CARL ALLEN ST
MOUNT VERNON MO
65712-1612
US

IV. Provider business mailing address

624 W SPRINGFIELD ST
AURORA MO
65605-1850
US

V. Phone/Fax

Practice location:
  • Phone: 417-461-7018
  • Fax: 417-461-7026
Mailing address:
  • Phone: 417-678-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2006020322
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: