Healthcare Provider Details

I. General information

NPI: 1265500243
Provider Name (Legal Business Name): TAILORED OCCUPATIONAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 THORNTON RD STE 125
LITHIA SPRINGS GA
30122-1589
US

IV. Provider business mailing address

PO BOX 943
AUSTELL GA
30168-1053
US

V. Phone/Fax

Practice location:
  • Phone: 770-577-0399
  • Fax: 678-922-1515
Mailing address:
  • Phone: 678-637-7812
  • Fax: 678-922-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT001309
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANA L HARRIS
Title or Position: CEO
Credential: OT
Phone: 678-637-7812