=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104906437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN MICHAEL NEVILLE MPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 02/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1930 HIGHLAND AVE SUITE A
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-481-9105
-----------------------------------------------------
Fax | 706-481-9107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1930 HIGHLAND AVE SUITE A
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-481-9105
-----------------------------------------------------
Fax | 706-481-9107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT007079
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 4215
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------