Provider Demographics
NPI:1790415982
Name:HART, JULIE A (COTA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:HART
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 1:21318 N RICHVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-8521
Mailing Address - Country:US
Mailing Address - Phone:618-335-8998
Mailing Address - Fax:
Practice Address - Street 1:208 ZACHERY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6712
Practice Address - Country:US
Practice Address - Phone:618-205-5257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003413224Z00000X
IL057.003413224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant