=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164663209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMY P HORN COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2009
-----------------------------------------------------
Last Update Date | 03/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2299 METROPOLIS ST
-----------------------------------------------------
City | METROPOLIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62960-1320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-524-2634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2299 METROPOLIS ST
-----------------------------------------------------
City | METROPOLIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62960-1320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-524-2634
-----------------------------------------------------
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 | 057.001549
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------