Provider Demographics
NPI:1063583425
Name:MARCUS, MARY AMANDA (LPT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:AMANDA
Last Name:MARCUS
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 WESTWIND DR
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-7722
Mailing Address - Country:US
Mailing Address - Phone:770-378-0075
Mailing Address - Fax:770-205-6315
Practice Address - Street 1:230 WESTWIND DR
Practice Address - Street 2:
Practice Address - City:BALL GROUND
Practice Address - State:GA
Practice Address - Zip Code:30107-7722
Practice Address - Country:US
Practice Address - Phone:770-378-0075
Practice Address - Fax:770-205-6315
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist