MEDICARE: KRISTI MARLEY 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	057002668	IL

General Provider Information

NPI Number	:	1205495389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTI MARLEY COTA/L

Provider Business Mailing Address
First Line	:	9099 POSSUM TRL
Second Line	:
City	:	FILLMORE
State	:	IL
Zip	:	62032-2105
Country	:	US
Telephone Number	:	217-638-3235
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 E 6TH ST
Second Line	:
City	:	PANA
State	:	IL
Zip	:	62557-1870
Country	:	US
Telephone Number	:	217-562-2174
Fax Number	:

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

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	06/11/2019

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Directions to “ KRISTI MARLEY COTA/L” Practice Location

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