Provider Demographics
NPI:1609442623
Name:PRIDEMORE, MARLEA TYLER (COTA)
Entity Type:Individual
Prefix:
First Name:MARLEA
Middle Name:TYLER
Last Name:PRIDEMORE
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 1:44 KNOLL DR APT C2
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-2769
Mailing Address - Country:US
Mailing Address - Phone:277-451-1915
Mailing Address - Fax:
Practice Address - Street 1:2412 KNOB CREEK RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2586
Practice Address - Country:US
Practice Address - Phone:423-518-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3548224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant