Provider Demographics
NPI:1720614720
Name:EHARDT, DANA (COTA)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:EHARDT
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 1:1513 N APPLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8078
Mailing Address - Country:US
Mailing Address - Phone:815-814-0033
Mailing Address - Fax:
Practice Address - Street 1:1513 N APPLEWOOD LN
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-8078
Practice Address - Country:US
Practice Address - Phone:815-814-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-21
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5702-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant