MEDICARE: EMILY FAXON 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	057.005548	IL

General Provider Information

NPI Number	:	1932784501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY FAXON COTA

Provider Business Mailing Address
First Line	:	2405 SHABBONA DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62702-1360
Country	:	US
Telephone Number	:	217-206-5713
Fax Number	:

Provider Business Practice Location Address
First Line	:	2508 SAINT JAMES RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-9736
Country	:	US
Telephone Number	:	217-747-5901
Fax Number	:

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

Provider Enumeration Date	:	03/15/2021
Last Update Date	:	03/15/2021

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