Provider Demographics
NPI:1386902997
Name:JOHNSON, GLORIA DELORES (COTA)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:DELORES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 N COASTAL HWY
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-3432
Mailing Address - Country:US
Mailing Address - Phone:912-880-4508
Mailing Address - Fax:
Practice Address - Street 1:652 N COASTAL HWY
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-3432
Practice Address - Country:US
Practice Address - Phone:912-880-4508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000933224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant