Provider Demographics
NPI:1629565874
Name:GORTH, VANESSA ANN (COTA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANN
Last Name:GORTH
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 1:832 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-2207
Mailing Address - Country:US
Mailing Address - Phone:812-560-2783
Mailing Address - Fax:
Practice Address - Street 1:832 E NORTH ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-2207
Practice Address - Country:US
Practice Address - Phone:812-560-2783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003090A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant