Provider Demographics
NPI:1659821148
Name:DAVIS, TAMARA ELAINE (COTA)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ELAINE
Last Name:DAVIS
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 1:6260 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-8930
Mailing Address - Country:US
Mailing Address - Phone:270-821-5644
Mailing Address - Fax:
Practice Address - Street 1:419 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1515
Practice Address - Country:US
Practice Address - Phone:270-821-5564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY134940224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant