Provider Demographics
NPI:1629617279
Name:HORRELL, WHITNEY NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:NICOLE
Last Name:HORRELL
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 1:10161 PINE CREST RD
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4458
Mailing Address - Country:US
Mailing Address - Phone:618-615-3984
Mailing Address - Fax:
Practice Address - Street 1:10161 PINE CREST RD
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-4458
Practice Address - Country:US
Practice Address - Phone:618-615-3984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005332224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL057005332OtherCERTIFICATION