Provider Demographics
NPI:1114382124
Name:MANN, TAKEISHA S (OTR/L)
Entity Type:Individual
Prefix:
First Name:TAKEISHA
Middle Name:S
Last Name:MANN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9137 LOXFORD ST
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-6414
Mailing Address - Country:US
Mailing Address - Phone:678-978-6614
Mailing Address - Fax:
Practice Address - Street 1:9137 LOXFORD ST
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-6414
Practice Address - Country:US
Practice Address - Phone:678-978-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005727225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics