Healthcare Provider Details

I. General information

NPI: 1215257191
Provider Name (Legal Business Name): BILLIE JO BEBOUT C.O.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 STONEMILL DR APT E
LYNCHBURG VA
24502-5075
US

IV. Provider business mailing address

406 STONEMILL DR APT E
LYNCHBURG VA
24502-5075
US

V. Phone/Fax

Practice location:
  • Phone: 434-941-0518
  • Fax:
Mailing address:
  • Phone: 434-941-0518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000308
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: