Provider Demographics
NPI:1205371622
Name:LATTIMORE, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:LATTIMORE
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 1:815 ATLANTA HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 GEORGE BUSBEE PKWY NW
Practice Address - Street 2:APT. 808
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6637
Practice Address - Country:US
Practice Address - Phone:678-522-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002148224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant