Provider Demographics
NPI:1316906605
Name:THEISS, JUSTIN LEE (DPT, DSCPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEE
Last Name:THEISS
Suffix:
Gender:M
Credentials:DPT, DSCPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3278 MITCHELL BLVD, MOODY AFB
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-1459
Mailing Address - Fax:
Practice Address - Street 1:3278 MITCHELL BLVD, MOODY AFB
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31699-1500
Practice Address - Country:US
Practice Address - Phone:229-257-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19632171000000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171000000XOther Service ProvidersMilitary Health Care Provider