Healthcare Provider Details

I. General information

NPI: 1720993306
Provider Name (Legal Business Name): MARIAH LAVENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 SMITHVILLE CHURCH RD
WARNER ROBINS GA
31088-7802
US

IV. Provider business mailing address

5111 PINEFIELD DR
MACON GA
31206-4717
US

V. Phone/Fax

Practice location:
  • Phone: 478-333-2333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT009997
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: