Provider Demographics
NPI:1649693391
Name:CHENOWETH, CASSANDRA (COTA)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:CHENOWETH
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 1:4727 230TH ST N
Mailing Address - Street 2:
Mailing Address - City:PORT BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61275-9427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6701 JERSEY RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3203
Practice Address - Country:US
Practice Address - Phone:563-386-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00760224Z00000X
IL057005308224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant