MEDICARE: LISA MARIE FRAHER DPT

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	225100000X	Physical Therapist	012005	GA
2	2251P0200X	Pediatric Physical Therapist	012005	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	012005	OTHER	GA	PT LICENSE

General Provider Information

NPI Number	:	1548636632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE FRAHER DPT

Provider Business Mailing Address
First Line	:	PO BOX 670207
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-0121
Country	:	US
Telephone Number	:	770-643-0868
Fax Number	:	770-643-0869

Provider Business Practice Location Address
First Line	:	2850 JOHNSON FERRY RD
Second Line	:	SUITE 100
City	:	MARIETTA
State	:	GA
Zip	:	30062-5684
Country	:	US
Telephone Number	:	770-643-0868
Fax Number	:	770-643-0869

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

Provider Enumeration Date	:	08/12/2015
Last Update Date	:	08/12/2015

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