Provider Demographics
NPI:1033290366
Name:WITHAM, LAURA SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUSAN
Last Name:WITHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 SILVER BLUFF RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-4709
Mailing Address - Country:US
Mailing Address - Phone:803-649-9797
Mailing Address - Fax:
Practice Address - Street 1:681 SILVER BLUFF RD
Practice Address - Street 2:SUITE A
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-4709
Practice Address - Country:US
Practice Address - Phone:803-649-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008511225100000X
SC4880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4880OtherPHYSICAL THERAPY LICENSE
GAPT008511OtherPHYSICAL THERAPY LICENSE