Provider Demographics
NPI:1902969173
Name:MCSPADDEN, SANDRA DIANE (OTRL)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DIANE
Last Name:MCSPADDEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 FOX BRUSH DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4857
Mailing Address - Country:US
Mailing Address - Phone:706-650-9024
Mailing Address - Fax:
Practice Address - Street 1:4405 EVANS TO LOCKS RD
Practice Address - Street 2:SUITE C
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3603
Practice Address - Country:US
Practice Address - Phone:706-854-1598
Practice Address - Fax:706-854-8136
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1795225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00979679AMedicaid