Provider Demographics
NPI:1831325109
Name:HAIRSTON, RENATA LEVON (COTA/L)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:LEVON
Last Name:HAIRSTON
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 1:202 AMY AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2602
Mailing Address - Country:US
Mailing Address - Phone:240-418-6909
Mailing Address - Fax:
Practice Address - Street 1:320 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1900
Practice Address - Country:US
Practice Address - Phone:276-666-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000360224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant