Provider Demographics
NPI:1265182570
Name:NEIDITCH, CHAVA
Entity type:Individual
Prefix:
First Name:CHAVA
Middle Name:
Last Name:NEIDITCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 MCCONNELL DR STE B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3507
Mailing Address - Country:US
Mailing Address - Phone:770-892-6878
Mailing Address - Fax:404-521-4121
Practice Address - Street 1:1270 MCCONNELL DR STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3507
Practice Address - Country:US
Practice Address - Phone:770-892-6878
Practice Address - Fax:404-521-4121
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005533225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty