Provider Demographics
NPI: | 1821190190 |
---|---|
Name: | LEWALLEN, ALICIA F (OT) |
Entity Type: | Individual |
Prefix: | |
First Name: | ALICIA |
Middle Name: | F |
Last Name: | LEWALLEN |
Suffix: | |
Gender: | F |
Credentials: | OT |
Other - Prefix: | |
Other - First Name: | ALLY |
Other - Middle Name: | FRANKLIN |
Other - Last Name: | LEWALLEN |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | OT |
Mailing Address - Street 1: | 8823 PRODUCTION LN |
Mailing Address - Street 2: | |
Mailing Address - City: | OOLTEWAH |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37363-6511 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 423-238-7217 |
Mailing Address - Fax: | 423-954-7408 |
Practice Address - Street 1: | 590 HISTORIC HIGHWAY 441 |
Practice Address - Street 2: | SUITE E |
Practice Address - City: | DEMOREST |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30535-4561 |
Practice Address - Country: | US |
Practice Address - Phone: | 706-754-6611 |
Practice Address - Fax: | 706-754-5834 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-05 |
Last Update Date: | 2014-02-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | OT1729 | 225X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | OT001729 | Other | OCCUPATIONAL THERAPY |
GA | 116807 | Medicare ID - Type Unspecified | GROUP NUMBER |