Healthcare Provider Details

I. General information

NPI: 1841528239
Provider Name (Legal Business Name): MELINDA HATTAWAY THRIFT OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 05/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 BENNETT RD
WAYCROSS GA
31503-1034
US

IV. Provider business mailing address

932 BENNETT RD
WAYCROSS GA
31503-1034
US

V. Phone/Fax

Practice location:
  • Phone: 912-286-2665
  • Fax: 912-285-3050
Mailing address:
  • Phone: 912-286-2665
  • Fax: 912-285-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1118
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT01118
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: