=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114130689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEAH C GUANLAO OTR-L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 02/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 OGLETHORPE DR NE
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30319-2774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-864-2004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 OGLETHORPE DR NE
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30319-2774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-864-2004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT005126
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------