Provider Demographics
NPI:1235478835
Name:ROYAL, MARY ALICE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:ROYAL
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 1:400 S INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-3972
Mailing Address - Country:US
Mailing Address - Phone:276-773-9447
Mailing Address - Fax:276-773-9447
Practice Address - Street 1:400 S INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348-3972
Practice Address - Country:US
Practice Address - Phone:276-773-9447
Practice Address - Fax:276-773-9447
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000441224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant