Provider Demographics
NPI:1740560499
Name:VANHPHOUMY, MENA K (COTA)
Entity Type:Individual
Prefix:
First Name:MENA
Middle Name:K
Last Name:VANHPHOUMY
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 1:30570 GREGORY DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-1243
Mailing Address - Country:US
Mailing Address - Phone:574-612-4708
Mailing Address - Fax:
Practice Address - Street 1:3109 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4372
Practice Address - Country:US
Practice Address - Phone:574-612-4708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN280293224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant