Provider Demographics
NPI:1043231160
Name:MOMON, KAWANA MONIQUE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:KAWANA
Middle Name:MONIQUE
Last Name:MOMON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5418 N 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-3321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 N MAYFAIR RD STE 200
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1403
Practice Address - Country:US
Practice Address - Phone:414-476-8183
Practice Address - Fax:414-476-8472
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1348-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40879900 (35/114)Medicaid
WI21280000Medicaid
WI3917061314OtherGROUP TAX ID