Healthcare Provider Details

I. General information

NPI: 1649747437
Provider Name (Legal Business Name): KATHERINE NATALIE BENJAMIN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KIRKWOOD RD
SAINT LOUIS MO
63122-7254
US

IV. Provider business mailing address

1001 S KIRKWOOD RD
SAINT LOUIS MO
63122-7254
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-7554
  • Fax:
Mailing address:
  • Phone: 314-821-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2015039646
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: