Provider Demographics
NPI:1275626459
Name:WILEY, LAURA (OT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 SIXES RD STE 126-235
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8192
Mailing Address - Country:US
Mailing Address - Phone:404-234-1370
Mailing Address - Fax:
Practice Address - Street 1:6478 PUTNAM FORD DR STE 124
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6987
Practice Address - Country:US
Practice Address - Phone:404-234-1370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003110225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000948645BMedicaid
GA000948648BMedicaid