Healthcare Provider Details

I. General information

NPI: 1255522033
Provider Name (Legal Business Name): LAURA JOHNSON TARRAGO MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5260 MANHASSET CT
ATLANTA GA
30338-3410
US

IV. Provider business mailing address

5260 MANHASSET CT
ATLANTA GA
30338-3410
US

V. Phone/Fax

Practice location:
  • Phone: 404-232-0920
  • Fax: 770-350-0754
Mailing address:
  • Phone: 404-232-0920
  • Fax: 770-350-0754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number002883
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: