=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487343158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOVE ACROSS THE LIFESPAN PHYSICAL THERAPY AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2023
-----------------------------------------------------
Last Update Date | 05/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 LOWRY ST NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-941-5001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 LOWRY ST NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-941-5001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. HEATHER IRENE MATHESON
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 404-941-5001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------