Healthcare Provider Details

I. General information

NPI: 1710170212
Provider Name (Legal Business Name): CHRISTIE DENEISE HURLEY COTA/L, BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RANDOLPH ST
RADFORD VA
24141-2430
US

IV. Provider business mailing address

1420 MILL IRON RD
GOODVIEW VA
24095-2940
US

V. Phone/Fax

Practice location:
  • Phone: 540-633-3708
  • Fax:
Mailing address:
  • Phone: 540-355-8909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1067502
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000398
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: