Provider Demographics
NPI:1285864595
Name:ROTH, BRIANNE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:MARIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 REINHARDT COLLEGE PKWY
Mailing Address - Street 2:SUITE 9
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5641
Mailing Address - Country:US
Mailing Address - Phone:770-345-3057
Mailing Address - Fax:770-345-3154
Practice Address - Street 1:147 REINHARDT COLLEGE PKWY
Practice Address - Street 2:SUITE 9
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5641
Practice Address - Country:US
Practice Address - Phone:770-345-3057
Practice Address - Fax:770-345-3154
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020058225100000X
GAPT009817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1801841374OtherGROUP NPI