Provider Demographics
NPI:1316375983
Name:CHILDRESS, DONNA MARIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:HAYSI
Mailing Address - State:VA
Mailing Address - Zip Code:24256-0846
Mailing Address - Country:US
Mailing Address - Phone:276-865-0324
Mailing Address - Fax:
Practice Address - Street 1:73 PIEDMONT DR
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7668
Practice Address - Country:US
Practice Address - Phone:606-633-3167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000473224Z00000X
KY135586224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant