Provider Demographics
NPI:1801924402
Name:WILES, SUSAN MARIE (OTRL)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WILES
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 STONEHILL WAY
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041
Mailing Address - Country:US
Mailing Address - Phone:770-265-7625
Mailing Address - Fax:770-410-9510
Practice Address - Street 1:2450 ATLANTA HWY STE 701
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1255
Practice Address - Country:US
Practice Address - Phone:404-834-8404
Practice Address - Fax:678-456-3437
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001803225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000742178CMedicaid