MEDICARE: LATASHA NICOLE MALLARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	OTA002989	GA

General Provider Information

NPI Number	:	1053183723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATASHA NICOLE MALLARD

Provider Business Mailing Address
First Line	:	150 COTTAGE LN
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-6200
Country	:	US
Telephone Number	:	770-830-8857
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 COTTAGE LN
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-6200
Country	:	US
Telephone Number	:	770-830-8857
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2023
Last Update Date	:	10/26/2023

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Directions to “ LATASHA NICOLE MALLARD ” Practice Location

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