Provider Demographics
NPI:1457545170
Name:RALSTON, LILA FRAZER (PTA)
Entity Type:Individual
Prefix:MS
First Name:LILA
Middle Name:FRAZER
Last Name:RALSTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LILA
Other - Middle Name:FRANCES
Other - Last Name:FRAZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 MOORES GROVE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WINTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30683-1506
Mailing Address - Country:US
Mailing Address - Phone:706-742-0082
Mailing Address - Fax:
Practice Address - Street 1:104 MOORES GROVE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WINTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30683-1506
Practice Address - Country:US
Practice Address - Phone:706-742-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002401225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant