Provider Demographics
NPI:1841261583
Name:BROWN, MARK TERRY (OTR/L)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:TERRY
Last Name:BROWN
Suffix:
Gender:M
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 1:613 WHITFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HOGANSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30230-3211
Mailing Address - Country:US
Mailing Address - Phone:706-845-8938
Mailing Address - Fax:
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-845-3677
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002040225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist