MEDICARE: MARLEIGH MLINAC STEVENSON DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT34566	FL

General Provider Information

NPI Number	:	1144885732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLEIGH MLINAC STEVENSON DPT

Provider Business Mailing Address
First Line	:	1100 CIRCLE 75 PKWY SE STE 1400
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-3067
Country	:	US
Telephone Number	:	678-981-3543
Fax Number	:	404-777-1311

Provider Business Practice Location Address
First Line	:	250 PALM COAST PKWY NE UNIT 209A
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-8289
Country	:	US
Telephone Number	:	386-597-1927
Fax Number	:	386-597-1926

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2019
Last Update Date	:	09/20/2021

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