Provider Demographics
NPI:1447589767
Name:BANNON, ROGER JAMES (OTR, CHT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:JAMES
Last Name:BANNON
Suffix:
Gender:M
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:JAMES
Other - Last Name:KOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3645 GENTIAN BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-5687
Mailing Address - Country:US
Mailing Address - Phone:706-507-4433
Mailing Address - Fax:
Practice Address - Street 1:3645 GENTIAN BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-5687
Practice Address - Country:US
Practice Address - Phone:706-507-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002316225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand