Provider Demographics
NPI:1639202831
Name:WYCKOFF, KIMBERLY A (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:GRATTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:1805 NOLLIE CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-6725
Mailing Address - Country:US
Mailing Address - Phone:440-506-0434
Mailing Address - Fax:
Practice Address - Street 1:933 CEDAR RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-7415
Practice Address - Country:US
Practice Address - Phone:757-382-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000945224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant