Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT006405 | GA |
NPI | 1003277708 |
---|---|
Provider Name | Anna Wicks |
First Address | Lawrenceville, GA 30046 |
Second Address | Lawrenceville, GA 30046 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2016 |
Last Update Date | 09/03/2016 |