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NPI Code Detail

MEDICARE: KACY MOSES GUSTAFSON COTA/L

MEDICARE: KACY MOSES GUSTAFSON COTA/L
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
1224Z00000XOccupational Therapy Assistant2572SC
2224Z00000XOccupational Therapy AssistantOTA000860GA

General Provider Information

NPI Number : 1952494338
Entity Type Code : Individual
Provider Name (Legal Business Name) : KACY MOSES GUSTAFSON COTA/L
Provider Business Mailing Address
First Line : 2421 CAMELOT DR
Second Line :
City : AUGUSTA
State : GA
Zip : 30904-3381
Country : US
Telephone Number : 706-799-3160
Fax Number :
Provider Business Practice Location Address
First Line : 350 AUSTIN GRAYBILL RD
Second Line :
City : NORTH AUGUSTA
State : SC
Zip : 29860-9251
Country : US
Telephone Number : 803-278-4272
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/30/2006
Last Update Date : 07/08/2007

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