Healthcare Provider Details

I. General information

NPI: 1417730599
Provider Name (Legal Business Name): KELLER GORDON PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 HOWARD ROBERTS RD
GRAY GA
31032-4003
US

IV. Provider business mailing address

907 HOWARD ROBERTS RD
GRAY GA
31032-4003
US

V. Phone/Fax

Practice location:
  • Phone: 404-593-4427
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016778
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: