Provider Demographics
NPI:1093236630
Name:BORSTELMANN, ERIC GLEN (COTA/L)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:GLEN
Last Name:BORSTELMANN
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 5TH ST W
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4307
Mailing Address - Country:US
Mailing Address - Phone:470-309-4953
Mailing Address - Fax:
Practice Address - Street 1:29 ADAMS WAY NW
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-5385
Practice Address - Country:US
Practice Address - Phone:470-309-4953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001923224Z00000X
TX213486224Z00000X
FLOTA17469224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant