Provider Demographics
NPI:1154515542
Name:FRAZIER, ETHEL LATARSHA (PT)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:LATARSHA
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 JOLANE TER SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3874
Mailing Address - Country:US
Mailing Address - Phone:770-785-7937
Mailing Address - Fax:770-785-7937
Practice Address - Street 1:3701 JOLANE TER SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3874
Practice Address - Country:US
Practice Address - Phone:770-785-7937
Practice Address - Fax:770-785-7937
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist