Provider Demographics
NPI:1083012785
Name:ENTENMAN, JOSHUA (COTA)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:ENTENMAN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12171 LOVE RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9640
Mailing Address - Country:US
Mailing Address - Phone:608-481-0400
Mailing Address - Fax:
Practice Address - Street 1:12171 LOVE RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9640
Practice Address - Country:US
Practice Address - Phone:608-481-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-11
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003947224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL057.003947OtherLICENSE NO.