Provider Demographics
NPI:1114691045
Name:MIDOCK, ERIKA LYNN (COTA, CLT)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:LYNN
Last Name:MIDOCK
Suffix:
Gender:F
Credentials:COTA, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 SCUFFLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-6540
Mailing Address - Country:US
Mailing Address - Phone:304-904-3464
Mailing Address - Fax:
Practice Address - Street 1:1170 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1618
Practice Address - Country:US
Practice Address - Phone:912-920-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001823224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant