Healthcare Provider Details

I. General information

NPI: 1396378477
Provider Name (Legal Business Name): CHANDRA A. MCCOY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 11/27/2023
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PLAZA DR
RAVENSWOOD WV
26164-1718
US

IV. Provider business mailing address

1 W SCHOOL ST
RIPLEY WV
25271-5279
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-9301
  • Fax:
Mailing address:
  • Phone: 304-372-7350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number069902841
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: