Healthcare Provider Details

I. General information

NPI: 1649608068
Provider Name (Legal Business Name): DENISE NICOLE DURHAM PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DENISE NICOLE JOHNSON PT

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2899 FIVE FORKS TRICKUM RD
LAWRENCEVILLE GA
30044-5803
US

IV. Provider business mailing address

1035 GUNTER CT
ALPHARETTA GA
30022-3503
US

V. Phone/Fax

Practice location:
  • Phone: 770-982-9969
  • Fax:
Mailing address:
  • Phone: 770-846-6336
  • Fax: 847-386-5196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number5562
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: