Healthcare Provider Details

I. General information

NPI: 1730574153
Provider Name (Legal Business Name): MAUREEN GONZALEZ COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 WESTLINE INDUSTRIAL DR. SUITE 201
ST LOUIS MO
63146
US

IV. Provider business mailing address

35 HAMPTON SPRINGS LANE
O FALLON MO
63368
US

V. Phone/Fax

Practice location:
  • Phone: 314-819-0480
  • Fax:
Mailing address:
  • Phone: 636-734-1922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2003030519
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: