Provider Demographics
NPI:1780340059
Name:AVERY, CHYNA (COTA)
Entity type:Individual
Prefix:
First Name:CHYNA
Middle Name:
Last Name:AVERY
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 1:8477 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:800-804-9961
Mailing Address - Fax:352-382-1146
Practice Address - Street 1:5100 RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-1553
Practice Address - Country:US
Practice Address - Phone:817-451-8001
Practice Address - Fax:352-382-1146
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216590224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant