Provider Demographics
NPI:1912359670
Name:HARRIS, TORYA LACHE' (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TORYA
Middle Name:LACHE'
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 RUSSELL PKWY STE 37
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8681
Mailing Address - Country:US
Mailing Address - Phone:478-352-1264
Mailing Address - Fax:
Practice Address - Street 1:2050 WATSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3625
Practice Address - Country:US
Practice Address - Phone:478-352-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001309224Z00000X
GAMT004335225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA81-3152487Medicaid
GA81-3152487Medicaid