Healthcare Provider Details

I. General information

NPI: 1538159843
Provider Name (Legal Business Name): COREEN L BOOKOUT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 COLLEGE ST SUITE E
CHRISTIANSBURG VA
24073-2958
US

IV. Provider business mailing address

80 COLLEGE ST SUITE E
CHRISTIANSBURG VA
24073-2958
US

V. Phone/Fax

Practice location:
  • Phone: 540-382-1492
  • Fax: 540-382-1493
Mailing address:
  • Phone: 540-382-1492
  • Fax: 540-382-1493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: