Provider Demographics
NPI:1487126827
Name:LOUGHRIDGE, SUMMER NICOLE
Entity type:Individual
Prefix:
First Name:SUMMER
Middle Name:NICOLE
Last Name:LOUGHRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13530 HIGHWAY 151
Mailing Address - Street 2:
Mailing Address - City:TRION
Mailing Address - State:GA
Mailing Address - Zip Code:30753-1930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2403 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4033
Practice Address - Country:US
Practice Address - Phone:423-595-4246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000920224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOTA000920Medicaid