Provider Demographics
NPI:1306343769
Name:PHAN, GLORIA TRAM (OTR/L)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:TRAM
Last Name:PHAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 WINDSONG LN SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3949
Mailing Address - Country:US
Mailing Address - Phone:678-524-8416
Mailing Address - Fax:
Practice Address - Street 1:4641 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3073
Practice Address - Country:US
Practice Address - Phone:404-474-0506
Practice Address - Fax:404-474-0515
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007021225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist