Provider Demographics
NPI:1366791089
Name:ROBERTS, CRYSTAL JILL (COTA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JILL
Last Name:ROBERTS
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 1:870 SHADY OAK DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-7735
Mailing Address - Country:US
Mailing Address - Phone:931-260-0997
Mailing Address - Fax:
Practice Address - Street 1:444 ONE ELEVEN PL
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-4358
Practice Address - Country:US
Practice Address - Phone:931-525-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1276224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant