MEDICARE: MRS. COLLEEN MARY CARLEY 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	057002496	IL

General Provider Information

NPI Number	:	1376829481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COLLEEN MARY CARLEY COTA/L

Provider Business Mailing Address
First Line	:	520 S 2ND ST APT 1601
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62701-1726
Country	:	US
Telephone Number	:	217-341-4724
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 S 2ND ST APT 1601
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62701-1726
Country	:	US
Telephone Number	:	217-341-4724
Fax Number	:

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

Provider Enumeration Date	:	11/02/2011
Last Update Date	:	11/02/2011

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