Provider Demographics
NPI:1104906437
Name:NEVILLE, SEAN MICHAEL (MPT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:MICHAEL
Last Name:NEVILLE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 HIGHLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-7800
Mailing Address - Country:US
Mailing Address - Phone:706-481-9105
Mailing Address - Fax:706-481-9107
Practice Address - Street 1:1930 HIGHLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-7800
Practice Address - Country:US
Practice Address - Phone:706-481-9105
Practice Address - Fax:706-481-9107
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007079225100000X
SC4215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4215OtherPHYSICAL THERAPY LICENSE
GAPT007079OtherPHYSICAL THERAPY LICENSE