Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XH1200X | Occupational Therapist - Hand | 000693 | GA |
NPI | 1043579683 |
---|---|
Provider Name | Jan Waldt |
First Address | Duluth, GA 30096-4807 |
Second Address | Duluth, GA 30096-4807 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2012 |
Last Update Date | 06/06/2012 |