Provider Demographics
NPI:1629243621
Name:DAS, MAMTA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MAMTA
Middle Name:
Last Name:DAS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 BAILEY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1710
Mailing Address - Country:US
Mailing Address - Phone:770-497-1617
Mailing Address - Fax:
Practice Address - Street 1:2950 OLD ALABAMA RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-8595
Practice Address - Country:US
Practice Address - Phone:770-475-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001633225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT001633OtherOT LICENSE