MEDICARE: ASHLEIGH LATHRAM OTR/L

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	225X00000X	Occupational Therapist	12146	NC

General Provider Information

NPI Number	:	1639632300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEIGH LATHRAM OTR/L

Provider Business Mailing Address
First Line	:	7710 FERRY LAUNCH WAY APT 5301
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-8685
Country	:	US
Telephone Number	:	937-403-7668
Fax Number	:	919-263-9605

Provider Business Practice Location Address
First Line	:	620 DR CALVIN JONES HWY
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-3100
Country	:	US
Telephone Number	:	919-673-4246
Fax Number	:	919-263-9605

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

Provider Enumeration Date	:	04/10/2019
Last Update Date	:	04/10/2019

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