Provider Demographics
NPI:1861829707
Name:UTLEY, ROBERT JEROME (COTA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JEROME
Last Name:UTLEY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HOSPITAL ROAD/IPMC
Mailing Address - Street 2:
Mailing Address - City:FT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-8212
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL ROAD / IPMC
Practice Address - Street 2:
Practice Address - City:FT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001471224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant