Provider Demographics
NPI:1972783595
Name:ANDRADA, MARIA SOCORRO REALES (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARIA SOCORRO
Middle Name:REALES
Last Name:ANDRADA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 RIVERSIDE DR
Mailing Address - Street 2:STE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-6900
Mailing Address - Country:US
Mailing Address - Phone:478-741-9672
Mailing Address - Fax:
Practice Address - Street 1:2129 RIVERSIDE DR
Practice Address - Street 2:STE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-6900
Practice Address - Country:US
Practice Address - Phone:478-741-9672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001371225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist