Provider Demographics
NPI:1134287907
Name:SPENCE, DINAH LYNN
Entity Type:Individual
Prefix:
First Name:DINAH
Middle Name:LYNN
Last Name:SPENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5322 DEEP SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3628
Mailing Address - Country:US
Mailing Address - Phone:404-634-5291
Mailing Address - Fax:
Practice Address - Street 1:318 W PIKE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3234
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002640225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10037598OtherAMERIGROUP-AAKTS
GA00819277BMedicaid
GA307935OtherWELLCARE- AAKTS