Provider Demographics
NPI:1710380464
Name:LYTTLE, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:LYTTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 GULFPORT RUN
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-2963
Mailing Address - Country:US
Mailing Address - Phone:770-296-5177
Mailing Address - Fax:
Practice Address - Street 1:1151 GULFPORT RUN
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-2963
Practice Address - Country:US
Practice Address - Phone:770-296-5177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2017-11-14
Deactivation Date:2014-10-21
Deactivation Code:
Reactivation Date:2017-11-14
Provider Licenses
StateLicense IDTaxonomies
GA004715225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist