Healthcare Provider Details

I. General information

NPI: 1295371383
Provider Name (Legal Business Name): COURTNEY PRYDE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2019
Last Update Date: 11/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 N GAYTON RD
RICHMOND VA
23233-7017
US

IV. Provider business mailing address

709 TREYS DR
WINCHESTER VA
22601-3233
US

V. Phone/Fax

Practice location:
  • Phone: 804-360-1960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131002292
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: