Healthcare Provider Details

I. General information

NPI: 1760743991
Provider Name (Legal Business Name): CHRISTOPHER ANDRE BEAVERS COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 W PINE BLVD
SAINT LOUIS MO
63108-2205
US

IV. Provider business mailing address

4626 WHISPER LAKE DR
FLORISSANT MO
63033-4307
US

V. Phone/Fax

Practice location:
  • Phone: 314-371-0200
  • Fax:
Mailing address:
  • Phone: 314-680-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2010021288
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: