Provider Demographics
NPI:1639436652
Name:PROSSER, MINDY KAYE (OT)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:KAYE
Last Name:PROSSER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 THE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-2172
Mailing Address - Country:US
Mailing Address - Phone:770-893-9464
Mailing Address - Fax:
Practice Address - Street 1:280 THE OAKS DR
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-2172
Practice Address - Country:US
Practice Address - Phone:770-893-9464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-15
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002390225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist