Provider Demographics
NPI:1508682147
Name:LATHAM, CALLIE DIANE (OTR/L)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:DIANE
Last Name:LATHAM
Suffix:
Gender:
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 1:1050 MCDONOUGH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1524
Mailing Address - Country:US
Mailing Address - Phone:770-775-7861
Mailing Address - Fax:
Practice Address - Street 1:14557 US-19
Practice Address - Street 2:SUITE C
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224
Practice Address - Country:US
Practice Address - Phone:770-468-6941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT009340225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics