Provider Demographics
NPI:1306493812
Name:HALTOM, NEIL JACOB (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:JACOB
Last Name:HALTOM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 WISTERIA DR STE 420
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6160
Mailing Address - Country:US
Mailing Address - Phone:404-590-5366
Mailing Address - Fax:770-982-0015
Practice Address - Street 1:2336 WISTERIA DR STE 420
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6160
Practice Address - Country:US
Practice Address - Phone:404-590-5366
Practice Address - Fax:770-982-0015
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013487A225100000X
GAPT0151622251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports