Basic Information
| Provider Information | |||||||||
| NPI: | 1750991980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORREST | ||||||||
| FirstName: | REVA | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 ATHENS AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306012008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885312204 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 2649 HWY 91 | ||||||||
| Address2: | |||||||||
| City: | DONALSONVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398452631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292546543 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2020 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT007816 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.