Provider Demographics
NPI:1639904972
Name:CORDOVA VILLA, CRISTY (OTR/L)
Entity type:Individual
Prefix:
First Name:CRISTY
Middle Name:
Last Name:CORDOVA VILLA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4658
Mailing Address - Country:US
Mailing Address - Phone:732-895-8901
Mailing Address - Fax:
Practice Address - Street 1:1801 OAK TREE RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-2772
Practice Address - Country:US
Practice Address - Phone:732-767-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
46TR01020100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist