Provider Demographics
NPI:1699517755
Name:PENALOZA, QUETZALLI (COTA)
Entity type:Individual
Prefix:
First Name:QUETZALLI
Middle Name:
Last Name:PENALOZA
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 1:9831 STATE HIGHWAY 76
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MO
Mailing Address - Zip Code:65653-5442
Mailing Address - Country:US
Mailing Address - Phone:417-559-1814
Mailing Address - Fax:
Practice Address - Street 1:286 EASTLAWN AVE
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3702
Practice Address - Country:US
Practice Address - Phone:573-842-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023009181224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant