Provider Demographics
NPI:1407055163
Name:PRIVETT, WANDA LYNN (COTA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LYNN
Last Name:PRIVETT
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 1:212 COUNTY RD 136
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:AL
Mailing Address - Zip Code:35540
Mailing Address - Country:US
Mailing Address - Phone:256-747-1719
Mailing Address - Fax:
Practice Address - Street 1:251 SUNSET PL
Practice Address - Street 2:
Practice Address - City:GUIN
Practice Address - State:AL
Practice Address - Zip Code:35563-2239
Practice Address - Country:US
Practice Address - Phone:205-468-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2664224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant