Healthcare Provider Details

I. General information

NPI: 1326309873
Provider Name (Legal Business Name): ANTHONY DEWAYNE TOWNSEND COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 MCLARAN AVE
SAINT LOUIS MO
63147-1606
US

IV. Provider business mailing address

4153 WASHINGTON BLVD
SAINT LOUIS MO
63108-3134
US

V. Phone/Fax

Practice location:
  • Phone: 314-388-4121
  • Fax: 314-395-3103
Mailing address:
  • Phone: 314-315-2264
  • Fax: 314-652-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2010015742
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.003235
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: