Provider Demographics
NPI:1841713906
Name:KIMBALL, HALEY (COTA)
Entity type:Individual
Prefix:MISS
First Name:HALEY
Middle Name:
Last Name:KIMBALL
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 1:5204 HIWASSEE CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-7984
Mailing Address - Country:US
Mailing Address - Phone:757-348-2504
Mailing Address - Fax:
Practice Address - Street 1:5871 HARBOUR VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3669
Practice Address - Country:US
Practice Address - Phone:757-819-5997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131-001814224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0131001814OtherCOTA LICENSE