Provider Demographics
NPI:1669696894
Name:PAYNE, MARLA ODOM (PT)
Entity type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:ODOM
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 921
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-0921
Mailing Address - Country:US
Mailing Address - Phone:770-943-7979
Mailing Address - Fax:770-943-7161
Practice Address - Street 1:1680 HIRAM DOUGLASVILLE HWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3739
Practice Address - Country:US
Practice Address - Phone:770-943-7979
Practice Address - Fax:770-943-7161
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0060342251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10052035Medicaid
GA347931Medicaid