Provider Demographics
NPI:1205296886
Name:JOSE, BETHANY RACHEAL (COTA)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:RACHEAL
Last Name:JOSE
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 1:309 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1756
Mailing Address - Country:US
Mailing Address - Phone:815-721-3239
Mailing Address - Fax:
Practice Address - Street 1:1605 SIDENER HALL
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-2401
Practice Address - Country:US
Practice Address - Phone:217-381-8487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant