Healthcare Provider Details

I. General information

NPI: 1477294551
Provider Name (Legal Business Name): LEHEA RENAE SCHUPP COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 E NIZHONI BLVD
GALLUP NM
87301-5794
US

IV. Provider business mailing address

113 S OHIO ST
CHRISMAN IL
61924-1525
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9551
  • Fax:
Mailing address:
  • Phone: 217-822-3293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.004112
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA4653
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: