Provider Demographics
NPI:1679819205
Name:GOBLE, ANNA PORTER (MSOT/RL)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:PORTER
Last Name:GOBLE
Suffix:
Gender:F
Credentials:MSOT/RL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ANASTASIA DR SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1461
Mailing Address - Country:US
Mailing Address - Phone:702-481-0072
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2208
Practice Address - Country:US
Practice Address - Phone:404-686-1391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-01
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005543225X00000X
NV09-0165225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist