Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | OT005321 | GA |
NPI | 1083987168 |
---|---|
Provider Name | Lacey Patrice Hitchings |
First Address | Cordele, GA 31015-3208 |
Second Address | Cordele, GA 31015-3208 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2012 |
Last Update Date | 20/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
049979274 | GEORGIA DRIVER'S LICENSE (01) | GA |