=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275875163
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN CAROL WISE COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2013
-----------------------------------------------------
Last Update Date | 03/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 15TH ST # 2902
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30912-0004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-721-5223
-----------------------------------------------------
Fax | 706-721-5228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1446 HARPER ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30912-0012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-721-5223
-----------------------------------------------------
Fax | 706-721-5228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA 000112
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------