Provider Demographics
NPI:1497533657
Name:PURVIS, GRACE MADISON (COTA/L)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MADISON
Last Name:PURVIS
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 1:2021 HOME PARK TRL APT 312
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-7808
Mailing Address - Country:US
Mailing Address - Phone:334-300-8556
Mailing Address - Fax:
Practice Address - Street 1:4209 CARMICHAEL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3601
Practice Address - Country:US
Practice Address - Phone:334-356-1020
Practice Address - Fax:334-356-2177
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5919224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant