Healthcare Provider Details

I. General information

NPI: 1245151257
Provider Name (Legal Business Name): MATTHEW JOHN MARSHALL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 DOWDY RD STE 203
ATHENS GA
30606-5700
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 762-728-4440
  • Fax: 762-728-4441
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA005530
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: