Provider Demographics
NPI:1386846558
Name:BETTS, LORI B (MPT)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:B
Last Name:BETTS
Suffix:
Gender:F
Credentials:MPT
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 74
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:GA
Mailing Address - Zip Code:31647-0074
Mailing Address - Country:US
Mailing Address - Phone:229-896-2797
Mailing Address - Fax:229-896-1629
Practice Address - Street 1:510 N PARRISH AVE
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-2036
Practice Address - Country:US
Practice Address - Phone:229-896-2797
Practice Address - Fax:229-896-1629
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCQGMedicare ID - Type UnspecifiedPROVIDER ID NUMBER