=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083364962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRITTANY NICOLE HAYNES COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2022
-----------------------------------------------------
Last Update Date | 12/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 649 LEGACY PL
-----------------------------------------------------
City | MASCOUTAH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62258-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-448-0206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 319 QUARRY ST
-----------------------------------------------------
City | STAUNTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62088-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-792-4259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 057.005750
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------