Healthcare Provider Details

I. General information

NPI: 1699205260
Provider Name (Legal Business Name): KORI ALYSSA MEPHAM PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 KEITH BRIDGE RD STE C2
CUMMING GA
30041-5570
US

IV. Provider business mailing address

6397 LEE HWY STE 300
CHATTANOOGA TN
37421-2564
US

V. Phone/Fax

Practice location:
  • Phone: 678-455-8773
  • Fax: 678-455-8775
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-362-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT012893
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: