Healthcare Provider Details

I. General information

NPI: 1417354259
Provider Name (Legal Business Name): MARY GOWER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 WEST PEACHTREE STREET NW
ATLANTA GA
30308-1137
US

IV. Provider business mailing address

739 WEST PEACHTREE STREET. NW
ATLANTA GA
30044-1137
US

V. Phone/Fax

Practice location:
  • Phone: 404-602-4318
  • Fax: 404-607-0062
Mailing address:
  • Phone: 404-602-4318
  • Fax: 404-607-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License NumberOT006081
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: