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General NPI Number Information
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NPI Number | 1124669148
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Entity Type | Individual
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Provider Name | KRISTINE LOUISE MADURA COTA
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Gender | Female
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Dates
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Enumeration Date | 10/01/2019
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Last Update Date | 10/01/2019
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Provider Practice Location Address
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Address Line | 4239 N OAK PARK AVE
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City | CHICAGO
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State | IL
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Zip | 60634-1410
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Country | US
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Telephone | 219-614-8206
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Fax |
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Provider Business Mailing Address
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Address Line | 2415 NEW YORK AVE
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City | WHITING
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State | IN
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Zip | 46394-2145
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Country | US
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Telephone | 219-614-8206
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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 | 057003716
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 298567
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License Number State | IN
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