Provider Demographics
NPI:1104097559
Name:LANE, SAMANTHA (COTA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LANE
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 1:3503 WEDGEWOOD RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-4437
Mailing Address - Country:US
Mailing Address - Phone:540-400-0359
Mailing Address - Fax:
Practice Address - Street 1:3503 WEDGEWOOD RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-4437
Practice Address - Country:US
Practice Address - Phone:540-400-0359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000829224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant