Provider Demographics
NPI:1730726688
Name:CORNETT, SUSAN R (COTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:CORNETT
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 1:1700 FALLEN LEAF LN
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-5657
Mailing Address - Country:US
Mailing Address - Phone:512-788-0048
Mailing Address - Fax:
Practice Address - Street 1:1700 FALLEN LEAF LN
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-5657
Practice Address - Country:US
Practice Address - Phone:512-788-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216020224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty