Basic Information
| Provider Information | |||||||||
| NPI: | 1790864031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | TONI | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 518 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302370518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706318277 | ||||||||
| FaxNumber: | 7706319403 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 PROFESSIONAL DR # A | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300457698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705170839 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA001895 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | PTA001895 | 01 | GA | STATE LISC NUMBER | OTHER |