Provider Demographics
NPI:1407507353
Name:EDWARDS, ANITA JOY (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:JOY
Last Name:EDWARDS
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 1:1059 WEALTHY ST SE UNIT 301
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1059 WEALTHY ST SE UNIT 301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1690
Practice Address - Country:US
Practice Address - Phone:616-777-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224ZE0001X, 171400000X
MI5202003641405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
1009423OtherCERTIFIED OCCUPATIONAL THERAPY ASSISTANT
1210601573OtherNATIONAL ACADEMY OF SPORTS MEDICINE
MI5202003641OtherOCCUPATIONAL THERAPY ASSISTANT LICENSE