Healthcare Provider Details

I. General information

NPI: 1508682147
Provider Name (Legal Business Name): CALLIE DIANE LATHAM OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14557 US-19 SUITE C
GRIFFIN GA
30224
US

IV. Provider business mailing address

1050 MCDONOUGH RD
JACKSON GA
30233-1524
US

V. Phone/Fax

Practice location:
  • Phone: 770-468-6941
  • Fax:
Mailing address:
  • Phone: 770-775-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT009340
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT009340
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: