Provider Demographics
NPI:1922310630
Name:CALDWELL, SHANTA L (COTA)
Entity Type:Individual
Prefix:MS
First Name:SHANTA
Middle Name:L
Last Name:CALDWELL
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 1:2330 LOUISIANA AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 NEW FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031
Practice Address - Country:US
Practice Address - Phone:314-830-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008019516224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant