Healthcare Provider Details

I. General information

NPI: 1780097295
Provider Name (Legal Business Name): GENA MARIE THURSTON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 JOHNSON FERRY RD SUITE 100
MARIETTA GA
30068-2764
US

IV. Provider business mailing address

123 W MADISON ST SUITE 200
CHICAGO IL
60602-4511
US

V. Phone/Fax

Practice location:
  • Phone: 770-321-0155
  • Fax: 770-321-8426
Mailing address:
  • Phone: 312-624-8102
  • Fax: 312-496-3175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10036
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT011939
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: