Provider Demographics
NPI:1528699618
Name:BETTORF, BRIAN H (COTA-L)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:H
Last Name:BETTORF
Suffix:
Gender:M
Credentials:COTA-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:IL
Mailing Address - Zip Code:62037-0056
Mailing Address - Country:US
Mailing Address - Phone:618-208-1435
Mailing Address - Fax:
Practice Address - Street 1:3490 HUMBERT RD
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-7101
Practice Address - Country:US
Practice Address - Phone:618-465-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004017224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant