Healthcare Provider Details

I. General information

NPI: 1699595983
Provider Name (Legal Business Name): LIRITA RACHA CARTLEDGE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2024
Last Update Date: 10/12/2024
Certification Date: 10/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 DEANS BRIDGE RD
AUGUSTA GA
30906-7004
US

IV. Provider business mailing address

1103 CHAMBERS DR
HEPHZIBAH GA
30815-4485
US

V. Phone/Fax

Practice location:
  • Phone: 706-798-1430
  • Fax:
Mailing address:
  • Phone: 706-496-0557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA001125
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: