=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639635311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOREEN BURNETTE LPTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2019
-----------------------------------------------------
Last Update Date | 02/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 E WEST CONNECTOR
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-1194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-819-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1638 TWIN COURTS LN SW
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30008-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-310-1379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA000972
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------