Provider Demographics
NPI:1114482734
Name:ANDERSON, ERIN (COTA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:ABNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:2595 S WOLF CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-0572
Mailing Address - Country:US
Mailing Address - Phone:618-889-9244
Mailing Address - Fax:
Practice Address - Street 1:2595 S WOLF CREEK RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-0572
Practice Address - Country:US
Practice Address - Phone:618-889-9244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.0003265224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant