Provider Demographics
NPI:1487851739
Name:GARVIN, GREGORY ALLEN (COTA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALLEN
Last Name:GARVIN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 HUNTINGTON DR
Mailing Address - Street 2:865 NORTH ST
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39272
Mailing Address - Country:US
Mailing Address - Phone:601-613-4911
Mailing Address - Fax:601-948-6651
Practice Address - Street 1:416 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39272-4486
Practice Address - Country:US
Practice Address - Phone:601-371-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA1475224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant