Provider Demographics
NPI:1093881690
Name:AFFLECK, LOUISA L (OTR)
Entity Type:Individual
Prefix:
First Name:LOUISA
Middle Name:L
Last Name:AFFLECK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:LOUISA
Other - Middle Name:
Other - Last Name:LOTHROP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6560
Mailing Address - Fax:219-365-6561
Practice Address - Street 1:59 EXECUTIVE DRIVE SOUTH
Practice Address - Street 2:SUITE1100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2208
Practice Address - Country:US
Practice Address - Phone:404-778-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT-GA130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT-GA130OtherSTATE LISC NUMBER