Provider Demographics
NPI:1285924092
Name:CLARKE, KOLETTA RAE (COTA)
Entity type:Individual
Prefix:
First Name:KOLETTA
Middle Name:RAE
Last Name:CLARKE
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 1:13907 N DARTMOUTH LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-9823
Mailing Address - Country:US
Mailing Address - Phone:618-237-7444
Mailing Address - Fax:
Practice Address - Street 1:208 ZACHERY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6712
Practice Address - Country:US
Practice Address - Phone:618-204-5497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003262224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant