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General NPI Number Information
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NPI Number | 1114651452
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Entity Type | Individual
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Provider Name | BETHANY DANIELLE RANDALL COTA
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Gender | Female
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Dates
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Enumeration Date | 07/12/2022
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Last Update Date | 07/12/2022
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Provider Practice Location Address
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Address Line | 873 GROVE ST
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City | JACKSONVILLE
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State | IL
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Zip | 62650-2828
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Country | US
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Telephone | 217-479-3400
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Fax |
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Provider Business Mailing Address
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Address Line | 1076 NE 475 AVE
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City | WHITE HALL
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State | IL
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Zip | 62092-4024
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Country | US
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Telephone | 618-946-9219
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 057.005812
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License Number State | IL
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