Provider Demographics
NPI:1205057049
Name:DAVIS, GUSTAVIA C (LCOTA)
Entity type:Individual
Prefix:MS
First Name:GUSTAVIA
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCOTA
Other - Prefix:MS
Other - First Name:GUSTAVIA
Other - Middle Name:C
Other - Last Name:DAVIS-LYONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCOTA
Mailing Address - Street 1:8551 OLIVER AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1730
Mailing Address - Country:US
Mailing Address - Phone:225-716-2880
Mailing Address - Fax:
Practice Address - Street 1:1306 W ADMIRAL DOYLE DR
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-8552
Practice Address - Country:US
Practice Address - Phone:337-364-5472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTA.Z20612224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA22OtherLCOTA