Provider Demographics
NPI:1902542715
Name:ROTH, DANYELLE (COTA)
Entity Type:Individual
Prefix:
First Name:DANYELLE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 DRUID OAKS DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-6543
Mailing Address - Country:US
Mailing Address - Phone:229-415-9555
Mailing Address - Fax:
Practice Address - Street 1:3609 DRUID OAKS DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-6543
Practice Address - Country:US
Practice Address - Phone:229-415-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002831224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant