Provider Demographics
NPI:1801043971
Name:MEDLIN, TRACY (OTR/L)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 STILESBORO RD NW STE 210
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7742
Mailing Address - Country:US
Mailing Address - Phone:404-384-3650
Mailing Address - Fax:786-573-4809
Practice Address - Street 1:5150 STILESBORO RD NW
Practice Address - Street 2:SUITE 430
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7744
Practice Address - Country:US
Practice Address - Phone:770-218-2300
Practice Address - Fax:770-218-2201
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004265225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA877080133AMedicaid