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General NPI Number Information
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NPI Number | 1952660805
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Entity Type | Individual
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Provider Name | TERESA MAE WILLIS COTA/L
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Gender | Female
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Dates
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Enumeration Date | 05/14/2012
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Last Update Date | 05/14/2012
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Provider Practice Location Address
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Address Line | 881 BIFROST WAY
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City | LINDEN
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State | VA
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Zip | 22642-5931
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Country | US
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Telephone | 480-291-2380
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Fax |
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Provider Business Mailing Address
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Address Line | 881 BIFROST WAY
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City | LINDEN
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State | VA
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Zip | 22642-5931
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Country | US
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Telephone | 480-291-2380
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 0131000537
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License Number State | VA
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