Provider Demographics
NPI:1477307064
Name:FULCHER, TINA (COTA/L)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FULCHER
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 1:571 KEN LANE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148
Mailing Address - Country:US
Mailing Address - Phone:276-734-0102
Mailing Address - Fax:
Practice Address - Street 1:350 KINGS WAY RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-6631
Practice Address - Country:US
Practice Address - Phone:276-634-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131-002102224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant