Provider Demographics
NPI:1316377872
Name:KNOWLTON, MALINA (COTA)
Entity Type:Individual
Prefix:
First Name:MALINA
Middle Name:
Last Name:KNOWLTON
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:PO BOX 12094
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2094
Mailing Address - Country:US
Mailing Address - Phone:706-589-3773
Mailing Address - Fax:803-202-0334
Practice Address - Street 1:707 STANTON DR
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3264
Practice Address - Country:US
Practice Address - Phone:706-589-3773
Practice Address - Fax:803-202-0334
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA001324224Z00000X
SCSC3132224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant