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General NPI Number Information
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NPI Number | 1245816008
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Entity Type | Individual
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Provider Name | DANIEL STEVEN BREEDEN COTA/L
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Gender | Male
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Dates
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Enumeration Date | 03/22/2021
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Last Update Date | 03/22/2021
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Provider Practice Location Address
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Address Line | 601 LUTZ RD
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City | BLOOMINGTON
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State | IL
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Zip | 61704-8608
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Country | US
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Telephone | 309-557-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 203 N WEST ST
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City | GIFFORD
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State | IL
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Zip | 61847-9520
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Country | US
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Telephone | 309-251-0403
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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 | 057005478
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License Number State | IL
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