Provider Demographics
NPI:1033776950
Name:BACCHUS, ZABIDA (COTA)
Entity Type:Individual
Prefix:
First Name:ZABIDA
Middle Name:
Last Name:BACCHUS
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 1:6309 92ND AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-1635
Mailing Address - Country:US
Mailing Address - Phone:763-898-6034
Mailing Address - Fax:
Practice Address - Street 1:4002 LONDON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-2243
Practice Address - Country:US
Practice Address - Phone:218-625-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202265224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant