Healthcare Provider Details

I. General information

NPI: 1609493626
Provider Name (Legal Business Name): ELIZABETH GRACE BABCOCK PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CHURCH LN
VILLA RICA GA
30180-4720
US

IV. Provider business mailing address

212 RETREAT VLG
SAINT SIMONS ISLAND GA
31522-2403
US

V. Phone/Fax

Practice location:
  • Phone: 770-459-6533
  • Fax:
Mailing address:
  • Phone: 912-638-1444
  • Fax: 912-638-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT014671
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT014671
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: