Provider Demographics
NPI:1407053341
Name:STALLMAN, VIRGINIA CHAVEZ (COTA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:CHAVEZ
Last Name:STALLMAN
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 1:801 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-2020
Mailing Address - Country:US
Mailing Address - Phone:812-838-4185
Mailing Address - Fax:
Practice Address - Street 1:1415 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-9301
Practice Address - Country:US
Practice Address - Phone:812-838-6554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001434A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant