Provider Demographics
NPI:1154523678
Name:POWELL, DENISE MARIE (PT)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:POWELL
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 1:45 W. CROSSVILLE ROAD, SUITE 514
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2964
Mailing Address - Country:US
Mailing Address - Phone:770-642-9444
Mailing Address - Fax:855-223-5462
Practice Address - Street 1:45 W. CROSSVILLE ROAD, SUITE 514
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2964
Practice Address - Country:US
Practice Address - Phone:770-642-9444
Practice Address - Fax:855-223-5462
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA282006299DMedicaid
GA898718498AMedicaid