MEDICARE: MISS TERRY ANTOINETTE PETERS COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	224Z00000X-OTA	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0131000136	OTHER	VA	OTA LICENSE

General Provider Information

NPI Number	:	1275876476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TERRY ANTOINETTE PETERS COTA/L

Provider Business Mailing Address
First Line	:	46 DIAMOND DR
Second Line	:
City	:	NORTH DINWIDDIE
State	:	VA
Zip	:	23803-7495
Country	:	US
Telephone Number	:	804-861-0259
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 DIAMOND DR
Second Line	:
City	:	NORTH DINWIDDIE
State	:	VA
Zip	:	23803-7495
Country	:	US
Telephone Number	:	804-861-0259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2013
Last Update Date	:	04/05/2013

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