=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649849506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA EMMA COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2021
-----------------------------------------------------
Last Update Date | 06/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1715 DEKALB AVE STE 125
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-2753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-991-5760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 799 OXBOW AVE UNIT 115
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60543-8454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | IL
-----------------------------------------------------