Healthcare Provider Details

I. General information

NPI: 1891902649
Provider Name (Legal Business Name): DANIELLE ELISE WORTHAM P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 TOWN PARK BLVD
EVANS GA
30809-3487
US

IV. Provider business mailing address

415 TOWN PARK BLVD
EVANS GA
30809-3487
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-1707
  • Fax: 706-868-1351
Mailing address:
  • Phone: 706-868-1707
  • Fax: 706-868-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015647
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT23754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: