Healthcare Provider Details

I. General information

NPI: 1285126441
Provider Name (Legal Business Name): MARY CALDWELL DJIRE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANNA CALDWELL PT, DPT

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 PLEASANT HILL RD STE 100
DULUTH GA
30096-5143
US

IV. Provider business mailing address

4477 PINERIDGE CIR
DUNWOODY GA
30338-6540
US

V. Phone/Fax

Practice location:
  • Phone: 770-497-4228
  • Fax: 770-497-4474
Mailing address:
  • Phone: 706-271-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13325
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT013369
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: