Provider Demographics
NPI:1215278858
Name:WHITE, HAYWARD JR (LPTA)
Entity type:Individual
Prefix:
First Name:HAYWARD
Middle Name:
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 YOUNG JAMES CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-1469
Mailing Address - Country:US
Mailing Address - Phone:678-887-6644
Mailing Address - Fax:678-284-1699
Practice Address - Street 1:315 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2500
Practice Address - Country:US
Practice Address - Phone:770-991-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA000054225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant