Provider Demographics
NPI:1437455078
Name:GLOVER, LEE HAWKINS (PTA)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:HAWKINS
Last Name:GLOVER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 FORSYTH RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4527
Mailing Address - Country:US
Mailing Address - Phone:478-254-7010
Mailing Address - Fax:478-254-7012
Practice Address - Street 1:4523 FORSYTH RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4527
Practice Address - Country:US
Practice Address - Phone:478-254-7010
Practice Address - Fax:478-254-7012
Is Sole Proprietor?:No
Enumeration Date:2011-01-30
Last Update Date:2011-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002501225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA002501OtherGEORGIA STATE LICENSE