Provider Demographics
NPI:1073838413
Name:GARDNER-HATTAWAY, LACY LEE (OTD, OTR/L, C/NDT)
Entity Type:Individual
Prefix:DR
First Name:LACY
Middle Name:LEE
Last Name:GARDNER-HATTAWAY
Suffix:
Gender:F
Credentials:OTD, OTR/L, C/NDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 GA HIGHWAY 18 W
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-3734
Mailing Address - Country:US
Mailing Address - Phone:478-986-8527
Mailing Address - Fax:
Practice Address - Street 1:922 GA HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032-3734
Practice Address - Country:US
Practice Address - Phone:478-986-8527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005050225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA573697931DMedicaid