Provider Demographics
NPI:1164063855
Name:AINLEY, LAURA (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:AINLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 EAGLE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6932
Mailing Address - Country:US
Mailing Address - Phone:470-265-7175
Mailing Address - Fax:
Practice Address - Street 1:4580 TOWNE LAKE PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5521
Practice Address - Country:US
Practice Address - Phone:770-592-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003157225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant