Provider Demographics
NPI:1710445127
Name:DEGRAFFENREID-ELLIOTT, COURTNEY (OT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DEGRAFFENREID-ELLIOTT
Suffix:
Gender:F
Credentials:OT
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 500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0009
Mailing Address - Country:US
Mailing Address - Phone:678-249-7120
Mailing Address - Fax:
Practice Address - Street 1:2848 LENOX RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-6004
Practice Address - Country:US
Practice Address - Phone:678-249-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006822225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT006822OtherLICENSE NUMBER