=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215557921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLY CEE WITT GESITE MS, PT, CNDT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2020
-----------------------------------------------------
Last Update Date | 04/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11785 NORTHFALL LN STE 501&502
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30009-7971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-569-2274
-----------------------------------------------------
Fax | 678-899-6333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 MILLSTONE PKWY
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30188-6139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-216-9620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | PT008496
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------