Healthcare Provider Details

I. General information

NPI: 1699285262
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY OF GA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865B N DRUID HILLS RD NE
ATLANTA GA
30329-3924
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 404-228-3678
  • Fax: 678-705-3560
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KEVIN JOHANNESON
Title or Position: VP REVENUE CYCLE
Credential:
Phone: 423-238-2330