Provider Demographics
NPI:1366010167
Name:MAZE, LATODDIA SHEDOR
Entity Type:Individual
Prefix:
First Name:LATODDIA
Middle Name:SHEDOR
Last Name:MAZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 ROYER LN
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6068
Mailing Address - Country:US
Mailing Address - Phone:404-823-8437
Mailing Address - Fax:
Practice Address - Street 1:3701 ROYER LN
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6068
Practice Address - Country:US
Practice Address - Phone:404-956-4418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006942225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist