Provider Demographics
NPI:1184936668
Name:CAIN, ELIZABETH TARA (OTR/L)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:TARA
Last Name:CAIN
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 1:1711 SAINT ELMO DR APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1231
Mailing Address - Country:US
Mailing Address - Phone:706-366-2318
Mailing Address - Fax:
Practice Address - Street 1:705 17TH ST STE 407
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3514
Practice Address - Country:US
Practice Address - Phone:706-321-0930
Practice Address - Fax:706-571-0960
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004839225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA018074628AMedicaid