Provider Demographics
NPI:1124139605
Name:BANNER, GINGER LYNN (OTL)
Entity type:Individual
Prefix:
First Name:GINGER
Middle Name:LYNN
Last Name:BANNER
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:GINGER
Other - Middle Name:LYNN
Other - Last Name:BUTTRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1765 OLD WEST BROAD ST BLDG 2-200
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2887
Mailing Address - Country:US
Mailing Address - Phone:706-549-1663
Mailing Address - Fax:706-546-8792
Practice Address - Street 1:1765 OLD WEST BROAD ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2853
Practice Address - Country:US
Practice Address - Phone:706-549-1663
Practice Address - Fax:706-546-8792
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003203225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I670134Medicare PIN