Provider Demographics
NPI:1467082388
Name:MODARELLI, PAYTON A (OTR)
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:A
Last Name:MODARELLI
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2643
Mailing Address - Country:US
Mailing Address - Phone:803-543-9805
Mailing Address - Fax:
Practice Address - Street 1:1000 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3873
Practice Address - Country:US
Practice Address - Phone:864-979-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007602225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist