Provider Demographics
NPI:1164893137
Name:GANN, LAURA (COTA/L CPAM)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GANN
Suffix:
Gender:F
Credentials:COTA/L CPAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 MORAN LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-7767
Mailing Address - Country:US
Mailing Address - Phone:706-378-3383
Mailing Address - Fax:
Practice Address - Street 1:139 MORAN LAKE RD NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-7767
Practice Address - Country:US
Practice Address - Phone:706-378-3383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000958224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant