Healthcare Provider Details

I. General information

NPI: 1104188994
Provider Name (Legal Business Name): THU LENGUYEN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 11/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RANDOLPH ST.
RADFORD VA
24141
US

IV. Provider business mailing address

14612 STROUBLES CREEK RD.
BLACKSBURG VA
24060
US

V. Phone/Fax

Practice location:
  • Phone: 540-633-6533
  • Fax:
Mailing address:
  • Phone: 540-354-1005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131001027
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: