MEDICARE: DEANNA ELIZABETH WILDMAN 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	2017005627	MO

General Provider Information

NPI Number	:	1275055907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANNA ELIZABETH WILDMAN COTA/L

Provider Business Mailing Address
First Line	:	649 S OAK GROVE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-2829
Country	:	US
Telephone Number	:	417-718-1085
Fax Number	:

Provider Business Practice Location Address
First Line	:	1302 W SUNSET ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-5943
Country	:	US
Telephone Number	:	417-718-1085
Fax Number	:

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

Provider Enumeration Date	:	07/14/2017
Last Update Date	:	07/14/2017

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