Healthcare Provider Details

I. General information

NPI: 1972892412
Provider Name (Legal Business Name): JASON ANDREW ILLIG COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 HIGHLAND RD
BETHEL PARK PA
15102-1806
US

IV. Provider business mailing address

4800 T REX AVE SUITE 310
BOCA RATON FL
33431-4479
US

V. Phone/Fax

Practice location:
  • Phone: 412-831-6050
  • Fax:
Mailing address:
  • Phone: 412-726-7663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP002286L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: