Provider Demographics
NPI:1205832599
Name:BETZ, LARA E (PT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:E
Last Name:BETZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0504
Mailing Address - Country:US
Mailing Address - Phone:706-291-1780
Mailing Address - Fax:706-291-1782
Practice Address - Street 1:1711 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1623
Practice Address - Country:US
Practice Address - Phone:706-528-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA700068640AMedicaid
GAP00359215OtherRR MEDICARE
GA700068640HMedicaid
GA700068640HMedicaid