Healthcare Provider Details

I. General information

NPI: 1265604896
Provider Name (Legal Business Name): GWINNETT SPORTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 OAKLAND RD STE 2C
LAWRENCEVILLE GA
30044-3758
US

IV. Provider business mailing address

965 OAKLAND RD STE 2C
LAWRENCEVILLE GA
30044-3758
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-2228
  • Fax: 770-962-2332
Mailing address:
  • Phone: 770-962-2228
  • Fax: 770-962-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT004490
License Number StateGA

VIII. Authorized Official

Name: MRS. SONYA WEAVER WRIGHT
Title or Position: MANAGER
Credential: MPT
Phone: 770-962-2228