Provider Demographics
NPI:1609393321
Name:FLY, ROBERT (COTA/L)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FLY
Suffix:
Gender:M
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 1:187 MILAN HWY
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-6035
Mailing Address - Country:US
Mailing Address - Phone:731-693-4008
Mailing Address - Fax:
Practice Address - Street 1:8017 DOGWOOD LN
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-6805
Practice Address - Country:US
Practice Address - Phone:731-686-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA0000002906224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant