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General NPI Number Information
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NPI Number | 1669035432
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Entity Type | Individual
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Provider Name | JODY CAROL CANNON COTA/L
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Gender | Female
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Dates
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Enumeration Date | 04/17/2019
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Last Update Date | 04/17/2019
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Provider Practice Location Address
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Address Line | 1000 N ALLEN ST
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City | ROBINSON
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State | IL
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Zip | 62454-1114
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Country | US
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Telephone | 618-546-2695
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Fax |
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Provider Business Mailing Address
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Address Line | 2610 SPRINGFIELD AVE
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City | LAWRENCEVILLE
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State | IL
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Zip | 62439-1850
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Country | US
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Telephone | 812-887-8022
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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 | 057002015
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License Number State | IL
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