Provider Demographics
NPI:1043673676
Name:HALL, LETICIA AMBER (COTA)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:AMBER
Last Name:HALL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6208 TIMBERCREEK DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-8192
Mailing Address - Country:US
Mailing Address - Phone:903-691-9059
Mailing Address - Fax:
Practice Address - Street 1:1315 WALNUT ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-4446
Practice Address - Country:US
Practice Address - Phone:903-794-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213698224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant