Healthcare Provider Details

I. General information

NPI: 1063583425
Provider Name (Legal Business Name): MARY AMANDA MARCUS LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 WESTWIND DR
BALL GROUND GA
30107-7722
US

IV. Provider business mailing address

230 WESTWIND DR
BALL GROUND GA
30107-7722
US

V. Phone/Fax

Practice location:
  • Phone: 770-378-0075
  • Fax: 770-205-6315
Mailing address:
  • Phone: 770-378-0075
  • Fax: 770-205-6315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002999
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: