Provider Demographics
NPI:1144844416
Name:TELLER, MONICA ASHLEY (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:ASHLEY
Last Name:TELLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:A
Other - Last Name:WIDSTRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:8143 HOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8143 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1507
Practice Address - Country:US
Practice Address - Phone:219-743-7944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004010224Z00000X
IN32002653A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty