Healthcare Provider Details

I. General information

NPI: 1528576360
Provider Name (Legal Business Name): MAKAYLA HERRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2462 HIGHWAY 34 E STE E
NEWNAN GA
30265-2378
US

IV. Provider business mailing address

6100 VETERANS PKWY STE 11
COLUMBUS GA
31909-3514
US

V. Phone/Fax

Practice location:
  • Phone: 770-580-3057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017348
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number16-22148
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: