Provider Demographics
NPI:1164173316
Name:VANDEWALLE, TRICIA (COTA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:VANDEWALLE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:L
Other - Last Name:VAN DE WALLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:57 BEVERLY HTS
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-4616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 FISHERS STATION DR
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-9744
Practice Address - Country:US
Practice Address - Phone:585-924-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010838-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant