Provider Demographics
NPI:1184839292
Name:BUSINARO, MARK J (COTA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:BUSINARO
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 S WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2939
Mailing Address - Country:US
Mailing Address - Phone:618-253-8376
Mailing Address - Fax:
Practice Address - Street 1:2852 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5016
Practice Address - Country:US
Practice Address - Phone:573-335-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005037443224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant