Provider Demographics
NPI:1831804525
Name:STUKES, DIANE SIMONE (COTA/L)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:SIMONE
Last Name:STUKES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:SIMONE
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2567
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-2567
Mailing Address - Country:US
Mailing Address - Phone:706-842-5330
Mailing Address - Fax:706-842-5340
Practice Address - Street 1:3727 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-2398
Practice Address - Country:US
Practice Address - Phone:706-842-5330
Practice Address - Fax:706-842-5340
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
GARBT-23-252400106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant