Provider Demographics
NPI:1063872687
Name:HALL, SANDRA JEAN (COTA/L)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:HALL
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 1:2634 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3824
Mailing Address - Country:US
Mailing Address - Phone:563-333-2780
Mailing Address - Fax:563-333-2836
Practice Address - Street 1:700 WAVERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-4317
Practice Address - Country:US
Practice Address - Phone:563-333-2780
Practice Address - Fax:563-333-2836
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00225224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant