Provider Demographics
NPI:1437600897
Name:KOESTER, ANGELA (COTA/L)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:KOESTER
Suffix:
Gender:F
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 1:5250 N 100TH ST
Mailing Address - Street 2:
Mailing Address - City:DIETERICH
Mailing Address - State:IL
Mailing Address - Zip Code:62424-2024
Mailing Address - Country:US
Mailing Address - Phone:217-994-4977
Mailing Address - Fax:
Practice Address - Street 1:5250 N 100TH ST
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424
Practice Address - Country:US
Practice Address - Phone:217-994-4977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004384224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
24Z00000XOtherTAXONOMY CODE