MEDICARE: MATANA QUEEN WILLIAMS OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT008692	GA

General Provider Information

NPI Number	:	1285345371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATANA QUEEN WILLIAMS OTR/L

Provider Business Mailing Address
First Line	:	406 HARMONY GROVE RD
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-6512
Country	:	US
Telephone Number	:	404-643-7169
Fax Number	:

Provider Business Practice Location Address
First Line	:	790 N INDIAN CREEK DR
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-2302
Country	:	US
Telephone Number	:	404-955-8564
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2022
Last Update Date	:	12/08/2025

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