Individual
KACY MOSES GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
350 AUSTIN GRAYBILL RD, NORTH AUGUSTA, SC 29860-9251
(803) 278-4272
Mailing address
2421 CAMELOT DR, AUGUSTA, GA 30904-3381
(706) 799-3160
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
2572
SC
224Z00000X
Occupational Therapy Assistant
OTA000860
GA
Other
Enumeration date
09/30/2006
Last updated
07/08/2007
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