Provider Demographics
NPI:1245445659
Name:PURVIANCE, TIMOTHY ALAN (COTA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALAN
Last Name:PURVIANCE
Suffix:
Gender:M
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:PO BOX 19914
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79114-1914
Mailing Address - Country:US
Mailing Address - Phone:806-463-7523
Mailing Address - Fax:
Practice Address - Street 1:5108 PIN OAK DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79110-4625
Practice Address - Country:US
Practice Address - Phone:806-463-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209125224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant