Provider Demographics
NPI:1942990775
Name:PRACHT, CORY MICHAEL (COTA/L)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:MICHAEL
Last Name:PRACHT
Suffix:
Gender:M
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 1:28 ESCONDIDA LN
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-5406
Mailing Address - Country:US
Mailing Address - Phone:575-418-9328
Mailing Address - Fax:
Practice Address - Street 1:28 ESCONDIDA LN
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-5406
Practice Address - Country:US
Practice Address - Phone:575-418-9328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3408224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant