MEDICARE: KEISIA RIDDLE COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	2016010243	MO
2	225700000X	Massage Therapist	227007170	IL

General Provider Information

NPI Number	:	1205287240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISIA RIDDLE COTA/L

Provider Business Mailing Address
First Line	:	2058 DEL RIO DR
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-4112
Country	:	US
Telephone Number	:	618-922-6154
Fax Number	:

Provider Business Practice Location Address
First Line	:	2058 DEL RIO DR
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-4112
Country	:	US
Telephone Number	:	618-922-6154
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2016
Last Update Date	:	06/30/2016

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Directions to “ KEISIA RIDDLE COTA/L” Practice Location

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