Healthcare Provider Details

I. General information

NPI: 1871207357
Provider Name (Legal Business Name): TAYLOR LAWRENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 01/10/2023
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 UPPER RIVERDALE RD STE B10
JONESBORO GA
30236-1071
US

IV. Provider business mailing address

378 5TH ST NE APT 2
ATLANTA GA
30308-3734
US

V. Phone/Fax

Practice location:
  • Phone: 912-667-6045
  • Fax:
Mailing address:
  • Phone: 912-667-6045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT008712
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: