Provider Demographics
NPI:1013491729
Name:CRADDOCK, SOPHIA ANNMARIE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:ANNMARIE
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:SOPHIA
Other - Middle Name:ANNMARIE
Other - Last Name:CRADDOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:2442 BARN HORSE CT
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7505
Mailing Address - Country:US
Mailing Address - Phone:914-356-4756
Mailing Address - Fax:
Practice Address - Street 1:6600 PEACHTREE DUNWOODY RD BLDG 40030328
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6773
Practice Address - Country:US
Practice Address - Phone:678-587-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002315224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant