Provider Demographics
NPI:1427673524
Name:COTTRELL, DESIREE CHANEL
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:CHANEL
Last Name:COTTRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3335
Mailing Address - Country:US
Mailing Address - Phone:330-722-1069
Mailing Address - Fax:
Practice Address - Street 1:801 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3335
Practice Address - Country:US
Practice Address - Phone:330-722-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty