Provider Demographics
NPI:1467108654
Name:COTTEREL, MASON T (MAT, ATC)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:T
Last Name:COTTEREL
Suffix:
Gender:M
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 WYDOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3043
Mailing Address - Country:US
Mailing Address - Phone:408-477-0953
Mailing Address - Fax:
Practice Address - Street 1:SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE VC 2201
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-3043
Practice Address - Country:US
Practice Address - Phone:408-477-0953
Practice Address - Fax:618-650-5880
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program