Provider Demographics
NPI:1316170384
Name:ROBERTS, TELISHA KELLY (COTA/L)
Entity type:Individual
Prefix:
First Name:TELISHA
Middle Name:KELLY
Last Name:ROBERTS
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 1:1 PARK WEST CIR STE 108
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5552
Mailing Address - Country:US
Mailing Address - Phone:804-419-1536
Mailing Address - Fax:
Practice Address - Street 1:12001 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1460
Practice Address - Country:US
Practice Address - Phone:804-706-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000076224Z00000X
VA0019009488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist