Provider Demographics
NPI:1235567181
Name:VERSACE-VREELAND, GINA (COTA/L)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:VERSACE-VREELAND
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4435 NEWHALL DR.
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040
Mailing Address - Country:US
Mailing Address - Phone:678-648-9881
Mailing Address - Fax:
Practice Address - Street 1:4435 NEWHALL DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1302
Practice Address - Country:US
Practice Address - Phone:678-648-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001680224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant