Provider Demographics
NPI:1124318993
Name:PHILLIPS, DENIA M (PT)
Entity type:Individual
Prefix:
First Name:DENIA
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2466 LOST VALLEY TRL SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-2437
Mailing Address - Country:US
Mailing Address - Phone:770-712-1001
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 250
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1415
Practice Address - Country:US
Practice Address - Phone:404-943-1070
Practice Address - Fax:404-943-0890
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT010224225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA049095452OtherDRIVER'S LICENSE