Provider Demographics
NPI:1336506724
Name:SMITH, ANNE NISSILA (COTA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:NISSILA
Last Name:SMITH
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 1:22017 100TH CT SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-2537
Mailing Address - Country:US
Mailing Address - Phone:360-635-8582
Mailing Address - Fax:
Practice Address - Street 1:22017 100TH CT SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-2537
Practice Address - Country:US
Practice Address - Phone:360-635-8582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 60445101224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOC 60445101OtherCOTA LICENSE