Provider Demographics
NPI:1932332749
Name:CRUTCHER-DUBOSE, CAROL ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:CRUTCHER-DUBOSE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 MCDONOUGH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:922 MCDONOUGH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1522
Practice Address - Country:US
Practice Address - Phone:214-551-4855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001506224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant