MEDICARE: MRS. TANQUERAE KISSY-VIRGINIA COLE COTA

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	2010026845	MO

General Provider Information

NPI Number	:	1538420138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TANQUERAE KISSY-VIRGINIA COLE COTA

Provider Business Mailing Address
First Line	:	1218 SELLS AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63147-1506
Country	:	US
Telephone Number	:	314-642-5558
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 N HANLEY RD
Second Line	:
City	:	BERKELEY
State	:	MO
Zip	:	63134-2710
Country	:	US
Telephone Number	:	314-521-7471
Fax Number	:

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

Provider Enumeration Date	:	05/31/2012
Last Update Date	:	05/31/2012

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