Healthcare Provider Details

I. General information

NPI: 1659078210
Provider Name (Legal Business Name): STEPHANIE LOUISE BRESHEARS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE LOUISE HARRIS

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E GENE LATHROP DR
SHELDON MO
64784-9805
US

IV. Provider business mailing address

1001 W MAIN ST
SHELDON MO
64784-9207
US

V. Phone/Fax

Practice location:
  • Phone: 417-684-2629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224ZL0004X
TaxonomyLow Vision Occupational Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2019047625
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: