Provider Demographics
NPI:1700216298
Name:BROWN, LAVETTA MARIE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:LAVETTA
Middle Name:MARIE
Last Name:BROWN
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 1:308 N ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1141
Mailing Address - Country:US
Mailing Address - Phone:708-747-4685
Mailing Address - Fax:
Practice Address - Street 1:308 N ORCHARD DR
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1141
Practice Address - Country:US
Practice Address - Phone:708-747-4685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003861224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant