Provider Demographics
NPI:1144591181
Name:VANCE, SHERRY L (COTA)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:L
Last Name:VANCE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:SHERRY
Other - Middle Name:L
Other - Last Name:WAGSTAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:2621 15TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2621 15TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5201
Practice Address - Country:US
Practice Address - Phone:406-455-5902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1116224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant