Provider Demographics
NPI:1881758969
Name:COLAVECCHIO, DONNA MARIE (COTA)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:COLAVECCHIO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:MARIE
Other - Last Name:LYDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:3640 MUNDY MILL ROAD
Practice Address - Street 2:SUITE 102B
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30504
Practice Address - Country:US
Practice Address - Phone:770-287-8821
Practice Address - Fax:770-287-8797
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000547224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116807Medicare ID - Type Unspecified