Provider Demographics
NPI:1366152902
Name:DAVIS, HALEY SHANNON (COTA/L)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:SHANNON
Last Name:DAVIS
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 1:5810 CRISPIN ST APT 2H
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6092
Mailing Address - Country:US
Mailing Address - Phone:817-776-7163
Mailing Address - Fax:
Practice Address - Street 1:4550 SHENANDOAH AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-4749
Practice Address - Country:US
Practice Address - Phone:540-982-2860
Practice Address - Fax:540-342-7241
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002593224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant