Provider Demographics
NPI:1457744054
Name:BOYETT, KAREN (COTA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:BOYETT
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 1:2175 ORVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-2409
Mailing Address - Country:US
Mailing Address - Phone:618-407-6419
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:866-433-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.001334224Z00000X
MO004461224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant