=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659596443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL ANN DORDEA C.O.T.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17374 N 89TH AVE #1522
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85382-8118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-582-9173
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10787 N D DR
-----------------------------------------------------
City | KENDALLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46755-9727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-582-9173
-----------------------------------------------------
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 | 3839
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------