Basic Information
| Provider Information | |||||||||
| NPI: | 1962154179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUE | ||||||||
| FirstName: | AVA | ||||||||
| MiddleName: | |||||||||
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| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZEAGLER | ||||||||
| OtherFirstName: | AVA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1220 | ||||||||
| Address2: | |||||||||
| City: | RINCON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313261220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126676468 | ||||||||
| FaxNumber: | 9123244241 | ||||||||
| Practice Location | |||||||||
| Address1: | 5723 GA HIGHWAY 21 S | ||||||||
| Address2: | |||||||||
| City: | RINCON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313265554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126676468 | ||||||||
| FaxNumber: | 9123244241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2022 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT008305 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.