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
StateLicense IDTaxonomies
GAOT1729225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT001729OtherOCCUPATIONAL THERAPY
GA116807Medicare ID - Type UnspecifiedGROUP NUMBER