Healthcare Provider Details

I. General information

NPI: 1558032540
Provider Name (Legal Business Name): HARRISON PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 JOHNSON FERRY RD NE
ROSWELL GA
30075-5206
US

IV. Provider business mailing address

3455 JOHNSON FERRY RD NE
ROSWELL GA
30075-5206
US

V. Phone/Fax

Practice location:
  • Phone: 678-472-6707
  • Fax: 678-623-9781
Mailing address:
  • Phone: 678-472-6707
  • Fax: 678-623-9781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name: VICTORIA SHEPHERD
Title or Position: COORDINATOR
Credential:
Phone: 314-315-5148