Provider Demographics
NPI:1336650373
Name:CAMPBELL, BECKY (COTA)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:CAMPBELL
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 1:596 VICKARS RD
Mailing Address - Street 2:
Mailing Address - City:BLUFF CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37618-3302
Mailing Address - Country:US
Mailing Address - Phone:423-383-6836
Mailing Address - Fax:
Practice Address - Street 1:3209 BRISTOL HWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1515
Practice Address - Country:US
Practice Address - Phone:423-282-3311
Practice Address - Fax:423-282-5245
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2950224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant