Basic Information
Provider Information | |||||||||
NPI: | 1720193840 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEYMOUR | ||||||||
FirstName: | TAMMY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | COTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BENNETT | ||||||||
OtherFirstName: | TAMMY | ||||||||
OtherMiddleName: | RACHEL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | COTA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 818 NEWTOWN RD | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 23462 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574738016 | ||||||||
FaxNumber: | 7574733580 | ||||||||
Practice Location | |||||||||
Address1: | 818 NEWTOWN RD | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 23462 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574738016 | ||||||||
FaxNumber: | 7574733580 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 10/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   | 224Z00000X | 0131000548 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 4980093 | 05 | VA |   | MEDICAID |