Provider Demographics
NPI:1255877619
Name:KONRAD, MEGAN LOUISE (COTA/L)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LOUISE
Last Name:KONRAD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 LAUREL RIDGE DR # 4192
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30536-1934
Mailing Address - Country:US
Mailing Address - Phone:419-575-9082
Mailing Address - Fax:
Practice Address - Street 1:623 LAUREL RIDGE DR.
Practice Address - Street 2:BOX 4192
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30536
Practice Address - Country:US
Practice Address - Phone:419-575-9082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001916224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant