Provider Demographics
NPI:1902121999
Name:SLATTERY, TIMOTHY (COTA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:SLATTERY
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 1:2504 MEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46803-3131
Mailing Address - Country:US
Mailing Address - Phone:260-610-3611
Mailing Address - Fax:
Practice Address - Street 1:2504 MEDFORD DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46803-3131
Practice Address - Country:US
Practice Address - Phone:260-610-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1916224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant