Provider Demographics
NPI:1669726873
Name:ROE, EDWARD THOMAS JR (OT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:THOMAS
Last Name:ROE
Suffix:JR
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WOODFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210
Mailing Address - Country:US
Mailing Address - Phone:478-475-7988
Mailing Address - Fax:478-475-7974
Practice Address - Street 1:110 WOODFIELD DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5625
Practice Address - Country:US
Practice Address - Phone:478-475-7988
Practice Address - Fax:478-475-7974
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005565225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist