Provider Demographics
NPI:1558069724
Name:ANDERSON, BALEAH DENISE (COTA)
Entity Type:Individual
Prefix:
First Name:BALEAH
Middle Name:DENISE
Last Name:ANDERSON
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 1:1805 BOWDOIN DR # 1805
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4513
Mailing Address - Country:US
Mailing Address - Phone:706-251-3994
Mailing Address - Fax:
Practice Address - Street 1:3725 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6623
Practice Address - Country:US
Practice Address - Phone:706-251-3994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002874225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist