Healthcare Provider Details

I. General information

NPI: 1174642409
Provider Name (Legal Business Name): TRACY LAWAND KELSO COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 PERSINGER RD SW
ROANOKE VA
24015-3829
US

IV. Provider business mailing address

4951 POMEROY RD NW
ROANOKE VA
24017-4627
US

V. Phone/Fax

Practice location:
  • Phone: 540-343-1696
  • Fax:
Mailing address:
  • Phone: 540-793-1153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1056802
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: