Provider Demographics
NPI:1689149502
Name:VILLANUEVA SWAMP, SUSIE JOY (COTA/L)
Entity Type:Individual
Prefix:
First Name:SUSIE JOY
Middle Name:
Last Name:VILLANUEVA SWAMP
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SUSIE JOY
Other - Middle Name:
Other - Last Name:SWAMP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1401 CORNFIELD CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-6438
Mailing Address - Country:US
Mailing Address - Phone:757-971-1260
Mailing Address - Fax:
Practice Address - Street 1:3100 SHORE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1199
Practice Address - Country:US
Practice Address - Phone:757-496-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-06
Last Update Date:2018-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001620224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant