MEDICARE: RACHEL MARIE DERUS 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	0131000970	VA
2	224Z00000X	Occupational Therapy Assistant	04381	OH

General Provider Information

NPI Number	:	1700156668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHEL MARIE DERUS COTA/L

Provider Business Mailing Address
First Line	:	15636 WINDMILL POINT RD
Second Line	:
City	:	HUNTSBURG
State	:	OH
Zip	:	44046-8766
Country	:	US
Telephone Number	:	216-906-1025
Fax Number	:

Provider Business Practice Location Address
First Line	:	4829 41ST ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20016-1707
Country	:	US
Telephone Number	:	216-906-1025
Fax Number	:

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

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	03/05/2012

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