MEDICARE: MRS. TRACI TARA HARRISONMADGE COTAL

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	2006012245	MO

General Provider Information

NPI Number	:	1326246646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACI TARA HARRISONMADGE COTAL

Provider Business Mailing Address
First Line	:	7902 ARLINGTON AVE
Second Line	:
City	:	RAYTOWN
State	:	MO
Zip	:	64138-1901
Country	:	US
Telephone Number	:	816-337-2441
Fax Number	:

Provider Business Practice Location Address
First Line	:	7902 ARLINGTON AVE
Second Line	:
City	:	RAYTOWN
State	:	MO
Zip	:	64138-1901
Country	:	US
Telephone Number	:	816-337-2441
Fax Number	:

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

Provider Enumeration Date	:	07/08/2007
Last Update Date	:	07/08/2007

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