MEDICARE: HEATHER DAWN MACLEOD LAWDER PTA

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	225200000X	Physical Therapy Assistant	PTA00498	GA

General Provider Information

NPI Number	:	1518677384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER DAWN MACLEOD LAWDER PTA

Provider Business Mailing Address
First Line	:	12775 OAK FALLS DR
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30009-3062
Country	:	US
Telephone Number	:	770-309-1273
Fax Number	:

Provider Business Practice Location Address
First Line	:	11190 MEDLOCK BRIDGE RD
Second Line	:
City	:	JOHNS CREEK
State	:	GA
Zip	:	30097-2578
Country	:	US
Telephone Number	:	678-464-7162
Fax Number	:

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

Provider Enumeration Date	:	12/01/2022
Last Update Date	:	12/01/2022

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