Provider Demographics
NPI:1265636716
Name:HARRIS, ALICIA ANN (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 SWEET BIRCH WAY
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-1006
Mailing Address - Country:US
Mailing Address - Phone:404-358-1925
Mailing Address - Fax:
Practice Address - Street 1:950 SWEET BIRCH WAY
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1006
Practice Address - Country:US
Practice Address - Phone:404-358-1925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA103089875Medicaid