MEDICARE: MS. GUSTAVIA C DAVIS LCOTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	OTA.Z20612	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22	OTHER	LA	LCOTA

General Provider Information

NPI Number	:	1205057049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GUSTAVIA C DAVIS LCOTA

Provider Business Mailing Address
First Line	:	8551 OLIVER AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-1730
Country	:	US
Telephone Number	:	225-716-2880
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 W ADMIRAL DOYLE DR
Second Line	:
City	:	NEW IBERIA
State	:	LA
Zip	:	70560-8552
Country	:	US
Telephone Number	:	337-364-5472
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	02/13/2013

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