Provider Demographics
NPI:1043242837
Name:FRYE, TOMOE MARUTA (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:TOMOE
Middle Name:MARUTA
Last Name:FRYE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 MEYERS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3443
Mailing Address - Country:US
Mailing Address - Phone:479-466-5882
Mailing Address - Fax:
Practice Address - Street 1:5610 BERMUDA ROAD
Practice Address - Street 2:STE. A
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087
Practice Address - Country:US
Practice Address - Phone:678-684-3872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005059225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150477721Medicaid