Provider Demographics
NPI:1659617272
Name:CHANCE, WALTRINA (COTA)
Entity Type:Individual
Prefix:
First Name:WALTRINA
Middle Name:
Last Name:CHANCE
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 1:302 WILLIAMSBURG RD APT 5104
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-6586
Mailing Address - Country:US
Mailing Address - Phone:
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:706-868-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
GA001519224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant