Healthcare Provider Details

I. General information

NPI: 1467668087
Provider Name (Legal Business Name): MARIE SHERWINE ALTIDOR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6849 PEACHTREE DUNWOODY RD NE BLDG B-1 SUITE 102
ATLANTA GA
30328-1610
US

IV. Provider business mailing address

237 HICKORY BRANCH DR
ACWORTH GA
30101-8773
US

V. Phone/Fax

Practice location:
  • Phone: 866-587-9922
  • Fax: 678-587-9993
Mailing address:
  • Phone: 678-574-9071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA002226
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: