Provider Demographics
NPI:1760956155
Name:SCREEN, KIARA DE'LANE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:KIARA
Middle Name:DE'LANE
Last Name:SCREEN
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 1:4121 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-6017
Mailing Address - Country:US
Mailing Address - Phone:434-222-8023
Mailing Address - Fax:
Practice Address - Street 1:103 ROSEHILL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4843
Practice Address - Country:US
Practice Address - Phone:434-517-7527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001261224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant