Provider Demographics
NPI:1689338857
Name:SPILLER, OCTAVIA MAEONQUE (PTA)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:MAEONQUE
Last Name:SPILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 GRAND POINTE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5502
Mailing Address - Country:US
Mailing Address - Phone:810-695-8920
Mailing Address - Fax:
Practice Address - Street 1:1330 GRAND POINTE CT
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5502
Practice Address - Country:US
Practice Address - Phone:810-695-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002111225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant