Healthcare Provider Details

I. General information

NPI: 1679293310
Provider Name (Legal Business Name): KENNEDY FABIAN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 TRAVIS ST
LA CROSSE WI
54601-6835
US

IV. Provider business mailing address

1765 BROGAN DR
NEW LENOX IL
60451-4016
US

V. Phone/Fax

Practice location:
  • Phone: 608-789-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number7094-27
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.005857
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: