Provider Demographics
NPI:1083951578
Name:TRIMBLE, GEOFFRE (COTA)
Entity Type:Individual
Prefix:
First Name:GEOFFRE
Middle Name:
Last Name:TRIMBLE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 KAIBAB TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3579
Mailing Address - Country:US
Mailing Address - Phone:260-519-3183
Mailing Address - Fax:
Practice Address - Street 1:4719 KAIBAB TRL
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-3579
Practice Address - Country:US
Practice Address - Phone:260-519-3183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002271A224Z00000X
IL057.003713224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant