Provider Demographics
NPI:1093747503
Name:ROSENBAUM, LOLA SICARD (DPT, PT, MHS, OCS)
Entity Type:Individual
Prefix:DR
First Name:LOLA
Middle Name:SICARD
Last Name:ROSENBAUM
Suffix:
Gender:F
Credentials:DPT, PT, MHS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 OSIGIAN BLVD
Mailing Address - Street 2:THE CANTRELL CENTER FOR PHYSICAL THERAPY & SPORTS MEDIC
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-953-3535
Mailing Address - Fax:478-953-0353
Practice Address - Street 1:405 OSIGIAN BLVD
Practice Address - Street 2:THE CANTRELL CENTER FOR PHYSICAL THERAPY & SPORTS MEDIC
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-953-3535
Practice Address - Fax:478-953-0353
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007078225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA570901821AMedicaid
GA52130765OtherBCBS
GA570901821AMedicaid