Provider Demographics
NPI:1275650202
Name:FAWLEY, RENEE DENISE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:DENISE
Last Name:FAWLEY
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 1:318 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-1283
Mailing Address - Country:US
Mailing Address - Phone:304-530-7857
Mailing Address - Fax:
Practice Address - Street 1:HC 63 BOX 2580
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-9718
Practice Address - Country:US
Practice Address - Phone:304-822-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1334224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant