Provider Demographics
NPI:1265500243
Name:TAILORED OCCUPATIONAL THERAPY LLC
Entity Type:Organization
Organization Name:TAILORED OCCUPATIONAL THERAPY LLC
Other - Org Name:TAILORED FOR TOTS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:678-637-7812
Mailing Address - Street 1:PO BOX 943
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-1053
Mailing Address - Country:US
Mailing Address - Phone:678-637-7812
Mailing Address - Fax:678-922-1515
Practice Address - Street 1:351 THORNTON RD STE 125
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1589
Practice Address - Country:US
Practice Address - Phone:770-577-0399
Practice Address - Fax:678-922-1515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001309174400000X
261QD1600X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000683812CMedicaid