Provider Demographics
NPI:1689185969
Name:DISHNER, PHYLLIS HOUSTON (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:HOUSTON
Last Name:DISHNER
Suffix:
Gender:F
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 1:518 POWELL AVE E
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-2346
Mailing Address - Country:US
Mailing Address - Phone:276-275-1500
Mailing Address - Fax:276-275-1500
Practice Address - Street 1:628 LAKE ST NE
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-7919
Practice Address - Country:US
Practice Address - Phone:276-275-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000931224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8409140OtherINSURANCE BROKER