Provider Demographics
NPI:1750460507
Name:LAWRENCE, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:LAWRENCE
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 1:1432 TOWNE LAKE PKWY
Mailing Address - Street 2:STE 120
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8263
Mailing Address - Country:US
Mailing Address - Phone:678-445-9799
Mailing Address - Fax:678-445-2688
Practice Address - Street 1:1432 TOWNE LAKE PKWY
Practice Address - Street 2:STE 120
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8263
Practice Address - Country:US
Practice Address - Phone:678-445-9799
Practice Address - Fax:678-445-2688
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT007675OtherLICENSE#
GAGRP7913OtherMEDICARE GROUP/FACILITY ID
GA202I651295Medicare PIN