Provider Demographics
NPI:1396152237
Name:DEOGRACIAS, AILEEN (OTR/L)
Entity type:Individual
Prefix:MS
First Name:AILEEN
Middle Name:
Last Name:DEOGRACIAS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 GRAND TETON PKWY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3096
Mailing Address - Country:US
Mailing Address - Phone:770-568-1099
Mailing Address - Fax:
Practice Address - Street 1:4230 GRAND TETON PKWY
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3096
Practice Address - Country:US
Practice Address - Phone:770-568-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT 004155225X00000X
CA9136225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT004155OtherGEORGIA STATE BOARD OF OCCUPATIONAL THERAPY