Provider Demographics
NPI:1174867600
Name:BALLENGER, TANYA DAWN (COTA)
Entity Type:Individual
Prefix:MISS
First Name:TANYA
Middle Name:DAWN
Last Name:BALLENGER
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 1:40 SMOKEY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:DANESE
Mailing Address - State:WV
Mailing Address - Zip Code:25831-7720
Mailing Address - Country:US
Mailing Address - Phone:304-575-0927
Mailing Address - Fax:
Practice Address - Street 1:405 STANAFORD RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3143
Practice Address - Country:US
Practice Address - Phone:304-252-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1512224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant