=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285484626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAH MCCORMACK COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2024
-----------------------------------------------------
Last Update Date | 03/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7222 W CERMAK RD STE 4104TH
-----------------------------------------------------
City | NORTH RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-442-0023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4531 S ELLIS AVE APT 2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60653-4998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-631-1709
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------