Provider Demographics
NPI:1770802092
Name:SOUTH, ASHLEY MICHELLE (OTR/L)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:SOUTH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:SOUTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:3222 VICKERY DR SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 SAMS ST STE A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-4101
Practice Address - Country:US
Practice Address - Phone:404-296-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005132225700000X
GAOT006119225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist